Complete RASS Reference
| Score | Level | Description | Assessment Method |
|---|---|---|---|
| +4 | Combative | Overtly combative, violent, immediate danger to staff | Observe patient |
| +3 | Very Agitated | Pulls/removes tubes or catheters; aggressive | Observe patient |
| +2 | Agitated | Frequent non-purposeful movement, fights ventilator | Observe patient |
| +1 | Restless | Anxious, apprehensive but movements not aggressive | Observe patient |
| 0 | Alert & Calm | Spontaneously alert and calm | Observe patient |
| −1 | Drowsy | Not fully alert; sustained eye contact >10s to voice | Call patient's name |
| −2 | Light Sedation | Brief awakening, eye contact <10s to voice | Call patient's name |
| −3 | Moderate Sedation | Movement/eye opening to voice, no eye contact | Call patient's name |
| −4 | Deep Sedation | No response to voice, movement to physical stimulation | Physical stimulation |
| −5 | Unarousable | No response to voice or physical stimulation | Physical stimulation |
Sedative Drug Guide — ICU
- Propofol (IV infusion): First-line for short-term sedation and when rapid awakening needed (e.g. neurological assessment). Start 0.5 mg/kg/hr, titrate to RASS target. Max 4 mg/kg/hr (propofol infusion syndrome risk at high doses >48h). Monitor triglycerides every 48h. Caution in haemodynamic instability
- Midazolam (IV infusion): Benzodiazepine, accumulates in obesity/renal failure. Use when propofol/dex unavailable. Associated with delirium (CAM-ICU). Avoid for prolonged sedation per PADIS 2018
- Dexmedetomidine (IV infusion): Alpha-2 agonist — sedation without respiratory depression, patients remain arousable. Preferred for light sedation (RASS 0 to −2) and delirium treatment. Start 0.2–0.7 µg/kg/hr. Bradycardia is main side effect
- Morphine / Fentanyl (IV): Analgesia first (A1C protocol) — treat pain before titrating sedation upward. Fentanyl preferred in renal failure (no active metabolite accumulation)
- Ketamine (bolus/infusion): Dissociative, bronchodilator, haemodynamically stimulating. Useful in reactive airways, haemodynamic instability, procedural sedation
Daily Spontaneous Awakening Trial (SAT) — ABCDEF Bundle
PADIS 2018 and the ABCDEF Bundle (A2F) recommend daily SAT (stopping sedation) and SBT (spontaneous breathing trial) in all eligible ICU patients. The AWAKENING AND BREATHING CONTROLLED (ABC) trial demonstrated reduced ICU LOS and mortality with paired SAT+SBT. Contraindications to SAT: active seizures, alcohol withdrawal, agitation requiring continuous sedation, FiO₂ >0.6 or PEEP >10 in ARDS, vasopressor escalation within 1h, active myocardial ischaemia.
Delirium Monitoring — CAM-ICU
All ICU patients should be assessed for delirium daily using the Confusion Assessment Method for ICU (CAM-ICU). CAM-ICU requires RASS ≥−3 to perform — patients at RASS −4 or −5 cannot be assessed. PADIS 2018 recommends: non-pharmacological prevention first (reorientation, sleep hygiene, early mobilisation, minimise sedation, treat pain, avoid benzodiazepines). Haloperidol and quetiapine are used for symptom management in hyperactive delirium but do not reduce duration.