RASS Assessment
Tap the level that best describes the patient's current state. Reassess every 2β4 hours in ICU.
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 |
| β1 | Drowsy | Not fully alert; sustained eye contact >10s to voice | Call patient's name |
| β2 | Light Sedation | Brief awakening, eye contact <10s to voice | Call patient's name |
| β3 | Moderate Sedation | Movement/eye opening to voice, no eye contact | Call patient's name |
| β4 | Deep Sedation | No response to voice, movement to physical stimulation | Physical stimulation |
| β5 | Unarousable | No response to voice or physical stimulation | Physical stimulation |
Sedative Drug Guide β 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 β sedation without respiratory depression, patients remain arousable. Preferred for light sedation (RASS 0 to β2) and delirium treatment. Start 0.2β0.7 Β΅g/kg/hr. Bradycardia is main side effect
- Morphine / Fentanyl (IV): Analgesia first (A1C protocol) β 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) β 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, FiOβ >0.6 or PEEP >10 in ARDS, vasopressor escalation within 1h, active myocardial ischaemia.
Delirium Monitoring β CAM-ICU
All ICU patients should be assessed for delirium daily using the Confusion Assessment Method for ICU (CAM-ICU). CAM-ICU requires RASS β₯β3 to perform β patients at RASS β4 or β5 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.
Frequently Asked Questions
What is the RASS scale?
The Richmond Agitation-Sedation Scale (RASS) assesses level of sedation and agitation in ICU patients. Scores: +4 Combative (violent), +3 Very agitated (pulls lines), +2 Agitated (purposeless movement), +1 Restless (anxious, not aggressive), 0 Alert and calm, -1 Drowsy (eyes open briefly to voice), -2 Light sedation (eyes open <10 sec to voice), -3 Moderate sedation (movement to voice, no eye contact), -4 Deep sedation (movement to physical stimulus only), -5 Unarousable.
What is the target RASS in mechanically ventilated patients?
SCCM/PADIS guidelines recommend targeting RASS 0 to -2 (light sedation) for most mechanically ventilated ICU patients. Light sedation is associated with shorter duration of mechanical ventilation, shorter ICU stay, and better cognitive outcomes compared to deep sedation (RASS -3 to -5). Deep sedation should be avoided unless specifically indicated (status epilepticus, severe ARDS on paralysis, elevated ICP).
How is RASS used for delirium assessment?
RASS is the prerequisite for delirium assessment using CAM-ICU (Confusion Assessment Method for ICU). CAM-ICU can only be performed when RASS is β₯-3. If RASS is -4 or -5 (unarousable/deeply sedated), delirium cannot be assessed β document as 'unable to assess' and aim to reduce sedation. Delirium assessment should be performed every 8-12 hours in all ICU patients.
What sedation agents are used in ICU?
Preferred agents (SCCM/PADIS guidelines): propofol (short-acting, easy to titrate, allows rapid awakening, lipid-based β monitor triglycerides) or dexmedetomidine (alpha-2 agonist, preserves arousability, reduces delirium, no respiratory depression β preferred for light sedation). Midazolam (benzodiazepine) is associated with more delirium and longer ICU stay β avoid for routine sedation. Ketamine useful as adjunct analgesic-sedative, especially in bronchospasm.
What is the ABCDEF bundle in ICU?
The ICU Liberation ABCDEF bundle: A β Assess, prevent, manage pain. B β Spontaneous Breathing Trial (daily SAT + SBT). C β Choice of analgesia/sedation (opioid-sparing, light sedation target). D β Delirium assessment and management (CAM-ICU, treat causes). E β Early mobility and Exercise. F β Family engagement and empowerment. Bundle implementation reduces ICU mortality, duration of mechanical ventilation, and delirium prevalence.
What causes agitation in ICU patients?
Common causes of agitation (RASS +1 to +4): pain (most common β assess with CPOT or NRS), delirium (hyperactive type), ventilator dysynchrony, urinary retention, constipation, anxiety, drug withdrawal (alcohol, benzodiazepines, opioids), hypoxia, hypercapnia, hypoglycaemia, and ICU psychosis. Always identify and treat the underlying cause before escalating sedation β adding more sedation to an agitated patient without addressing the cause worsens outcomes.
Related Calculators
β Medical Disclaimer: RASS assessment requires trained clinical or nursing staff. Sedation targets should be prescribed by the ICU physician and reassessed every 2β4 hours. Always integrate RASS with pain assessment (NRS/BPS), delirium monitoring (CAM-ICU), and clinical context. Never deepen sedation without identifying and treating the underlying cause of agitation.