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🏥 CRITICAL CARE · ICU · SEDATION DEPTH

Richmond Agitation-Sedation Scale (RASS)

Assess and target sedation depth in ICU and mechanically ventilated patients from −5 (unarousable) to +4 (combative). Aligned with PADIS 2018 guidelines.

Scale −5 to +4PADIS 2018 TargetsDaily SAT Reminder
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RASS Bedside Assessment

Tap the level describing patient's current state

PADIS 2018
📋 Contents — tap to expand
1. Complete RASS Reference Table2. ICU Sedative Drug Guide3. ABCDEF Bundle & CAM-ICU4. Frequently Asked Questions
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Reviewed by Dr. Sharma, MBBS AFIH

Medical Officer, AAC Clinic · Updated 2026-06-09

1Complete RASS Reference Table

ScoreLevelClinical DescriptionAssessment Procedure
+4CombativeOvertly combative, violent, immediate danger to staff.Observe patient behavior.
+3Very AgitatedPulls or removes tubes/catheters; aggressive.Observe patient behavior.
+2AgitatedFrequent non-purposeful movement, fights ventilator.Observe patient behavior.
+1RestlessAnxious, apprehensive but movements not aggressive.Observe patient behavior.
0Alert & CalmSpontaneously alert and calm.Observe patient behavior.
−1DrowsyNot fully alert; sustained eye contact >10s to voice.Call patient's name.
−2Light SedationBrief awakening, eye contact <10s to voice.Call patient's name.
−3Moderate SedationMovement/eye opening to voice, no eye contact.Call patient's name.
−4Deep SedationNo response to voice, movement to physical stimulation.Physical stimulation (shoulder shake).
−5UnarousableNo response to voice or physical stimulation.Physical stimulation.

2ICU Sedative Drug Guide (PADIS 2018)

Propofol (IV Infusion)

First-line for short-term ICU sedation and rapid neurological assessments. Start 0.5 mg/kg/hr, titrate to target RASS. Maximum 4 mg/kg/hr due to risk of Propofol Infusion Syndrome (PRIS) at high doses for >48h. Monitor triglycerides every 48 hours.

Dexmedetomidine (Alpha-2 Agonist)

Sedation without respiratory depression; patients remain cooperative and arousable. Strongly preferred by PADIS 2018 for light sedation (RASS 0 to −2) and delirium mitigation. Start 0.2–0.7 µg/kg/hr. Bradycardia is the primary dose-limiting side effect.

Midazolam (Benzodiazepine Infusion)

Accumulates significantly in obesity and renal failure. Associated with prolonged mechanical ventilation and increased incidence of ICU delirium. Per PADIS guidelines, avoid for routine maintenance sedation.

3Daily Spontaneous Awakening Trials (SAT) & CAM-ICU

PADIS 2018 and the ICU Liberation ABCDEF bundle recommend daily spontaneous awakening trials (SAT) paired with spontaneous breathing trials (SBT) in all eligible mechanically ventilated patients to minimize over-sedation.

Delirium Monitoring (CAM-ICU): Daily assessment using the Confusion Assessment Method for the ICU requires a baseline RASS of ≥−3. Patients at RASS −4 or −5 cannot be assessed for delirium and should be re-evaluated as sedation is lightened.

4Frequently Asked Questions

What is the target RASS in mechanically ventilated patients?+
SCCM/PADIS guidelines recommend targeting light sedation (RASS 0 to −2) for most mechanically ventilated ICU patients. Light sedation significantly shortens duration of mechanical ventilation and ICU stay compared to deep sedation.
How is RASS used for delirium assessment?+
RASS is the obligatory first step for CAM-ICU delirium screening. If a patient is at RASS −4 or −5, delirium testing cannot be performed; sedation must be lightened until RASS reaches ≥−3.
What causes agitation in ICU patients?+
Common causes of agitation (RASS +1 to +4) include untreated pain, hyperactive delirium, urinary retention, hypoxia, hypercapnia, ventilator dyssynchrony, and drug withdrawal. Always investigate and treat underlying causes before escalating sedative infusions.
Clinical Takeaway: Target light sedation (RASS 0 to −2) whenever clinical safety permits. Pair daily spontaneous awakening trials with structured delirium monitoring.
Medical Disclaimer: This clinical calculator is designed for ICU physicians, nurses, and allied health professionals. Sedation targets must be prescribed and monitored continuously according to local hospital protocols.