Richmond Agitation Sedation Scale (RASS Score) Calculator

How does this Richmond Agitation Sedation Scale (RASS Score) calculator work?

This is a health tool that is aimed at evaluating proper sedation in hospitalized patients or their level of agitation prospective to being sedated. It is a model that has been implemented after a through study and validation cohorts and looks mainly after patients with various conditions in the intensive care unit setting.

The tool originated in the Virginia Commonwealth University in Richmond and advises clinicians to observe the patient and also test their response to verbal and pain stimulation.

Patient status descriptions that are used in the Richmond Agitation Sedation Scale (RASS score) calculator and their explanations are detailed below:

■ Combative [4 points] – Indicates patient as overtly combative, violent and immediate danger to staff.

■ Very Agitated [3 points] – Indicates patient pulls or removes tube(s) or catheter(s) and/ or is being aggressive.

■ Agitated [2 points] – Indicates patient presents frequent non-purposeful movement and also fights ventilator risking self-extubation or ventilator dyssynchrony.

■ Restless [1 point] – Indicates patient is anxious but movements are not aggressive but vigorous.

■ Alert and Calm [0 points] – Indicates a cooperative patient who is sedated properly.

■ Drowsy [-1 point] – Indicates patient is not fully alert, but has sustained awakening (eye-opening/eye contact) to voice for more than 10 seconds.

■ Light Sedation [-2 points] – Indicates patient briefly awakens with eye contact to voice but for less than 10 seconds.

■ Moderate Sedation [-3 points] – Indicates patient does present some movement or eye opening to voice but no eye contact.

■ Deep Sedation [-4 points] – Indicates patient has no response to voice, but movement or eye opening to physical stimulation.

■ Unarousable Sedation [-5 points] – Indicates patient has no response to voice or physical stimulation.

RASS score interpretation

In the Richmond assessment scale there are 10 answer choices that describe quite in detail the patient status. Once the clinician chooses one of them, they will be given a numeric score, either a positive, a zero or a negative score. This is in turn interpreted as follows:

■ In RASS scores of above 0 the patient is not sedated enough and should be monitored for display of pain, anxiety and other symptoms. The medical professional should ensure the drug half times are calculated properly.

■ RASS scores of between -2 and 0 are the ones to aim for as they indicate a properly sedated patient who can be cooperative but at the same time it is dealt with pain and agitation. Often clinicians are advised to use minimal sedation in cases that don’t have a strict indication for deep sedation.

■ Scores below -2 indicate a patient who is sedated too much and for which sedation medication should be decreased.

Other considerations on the agitation sedation scale

The RASS score advocates for a proper use of sedation and aim to reduce resource cost, intravenous use of medication (10-15% of medicines used in ICU are for sedation purposes) and the patient stay in the intensive care units and as well decrease mechanical ventilation procedure times and even mortality rates in different conditions.

The Richmond Agitation Sedation Scale differs from the sedation levels (minimal, moderate, deep, general) that are often used by clinicians in accordance to the American Society of Anesthesia guidelines but these can be used together to provide an even more precise patient monitoring.

One of the main advantages of the scale is that can be used even in the case of mechanically ventilated patients and in assessing the risk for agitated patients to reject ventilation and to complicate their situation due to that in case they don’t receive proper sedative medication.

The model is used to analyze hospitalized patients that have been sedated to different degrees and to check their level of alertness although different from AVPU assessments that check level of consciousness of the patient before treatment.

The RASS do not offer precise information on the outcome but help the medical professionals understand whether the patient is sedated properly, whether the dosage should be higher or lower. It also precedes the Confusion Assessment Method which is further used in evaluating the presence of delirium in ICU patients.

A similar tool to RASS is the Ramsay Scale, below to be found a description of sedation levels:

1 Anxious and agitated.

2 Cooperative, tranquil, oriented.

3 Responds only to verbal commands.

4 Asleep with brisk response to light stimulation.

5 Asleep without response to light stimulation.

6 Non responsive.

References

1) Sessler CN, Grap MJ, Brophy GM. (2001) Multidisciplinary management of sedation and analgesia in critical care. Semin Respir Crit Care Med; 22(2):211-26.

2) Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, Francis J, Speroff T, Gautam S, Margolin R, Sessler CN, Dittus RS, Bernard GR. (2003) Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA; 289(22):2983-91.

3) Khan BA, Guzman O, Campbell NL, Walroth T, Tricker J, Hui SL, Perkins A, Zawahiri M, Buckley JD, Farber MO, Ely W, Boustani MA. (2012) Comparison and agreement between the Richmond Agitation-Sedation Scale and the Riker Sedation-Agitation Scale in evaluating patients' eligibility for delirium assessment in the ICU. Chest; 142(1):48-54.