The Richmond Agitation–Sedation Scale

Abstract

Sedative medications are widely used in intensive care unit (ICU) patients. Structured assessment of sedation and agitation is useful to titrate sedative medications and to evaluate agitated behavior, yet existing sedation scales have limitations. We measured inter-rater reliability and validity of a new 10-level (+4 "combative" to -5 "unarousable") scale, the Richmond Agitation-Sedation Scale (RASS), in two phases. In phase 1, we demonstrated excellent (r = 0.956, lower 90% confidence limit = 0.948; kappa = 0.73, 95% confidence interval = 0.71, 0.75) inter-rater reliability among five investigators (two physicians, two nurses, and one pharmacist) in adult ICU patient encounters (n = 192). Robust inter-rater reliability (r = 0.922-0.983) (kappa = 0.64-0.82) was demonstrated for patients from medical, surgical, cardiac surgery, coronary, and neuroscience ICUs, patients with and without mechanical ventilation, and patients with and without sedative medications. In validity testing, RASS correlated highly (r = 0.93) with a visual analog scale anchored by "combative" and "unresponsive," including all patient subgroups (r = 0.84-0.98). In the second phase, after implementation of RASS in our medical ICU, inter-rater reliability between a nurse educator and 27 RASS-trained bedside nurses in 101 patient encounters was high (r = 0.964, lower 90% confidence limit = 0.950; kappa = 0.80, 95% confidence interval = 0.69, 0.90) and very good for all subgroups (r = 0.773-0.970, kappa = 0.66-0.89). Correlations between RASS and the Ramsay sedation scale (r = -0.78) and the Sedation Agitation Scale (r = 0.78) confirmed validity. Our nurses described RASS as logical, easy to administer, and readily recalled. RASS has high reliability and validity in medical and surgical, ventilated and nonventilated, and sedated and nonsedated adult ICU patients.

Conscious Sedation and Awake Fiberoptic Intubation in a Patient with Difficult Mask Ventilation—A Case Report

“…Several classes of drugs including benzodiazepines, opioids, alpha 2 agonists, propofol, and ketamine have been reported for conscious sedation during AFOI [2]. Among them, dexmedetomidine is a highly selective, potent alpha 2 adrenergic receptor agonist.…”

“…For nasal decongestion and anesthesia, the right nasal cavity was packed with ribbon gauze soaked in 1% lidocaine and epinephrine solution (1:200,000) and was leftin place for 10 minutes. For conscious sedation, injection dexmedetomidine at 6 mcg/kg/hr was started and sedation was assessed with the Richmond agitation-sedation scale (RASS) [2]. After 10 minutes of dexmedetomidine infusion, the RASS score was 0 to −1, and the dose of dexmedetomidine was decreased to 0.4 mcg/kg/hr.…”

Brexanolone as adjunctive therapy in super‐refractory status epilepticus

“…Status Epilepticus Severity Score (STESS; range of 0–6), a validated tool for systematic evaluation of the outcome of SE patients, was tabulated by survival endpoints 30. Functional status of patients was monitored using Modified Rankin Scale‐9Q (mRS‐9Q; range of 0–5),31 Clinical Global Impression‐Severity/Improvement (CGI‐S/CGI‐I; range of 1–7),32 Richmond Agitation‐Sedation Scale (RASS; adults only; range of –5 to 4),33 Glasgow Coma Scale (GCS; range, 3–15),34 and the National Institutes of Health Stroke Scale (NIHSS; range of 0–42)35 scores.…”

Comparison of clinical practice guidelines for the management of pain, agitation, and delirium in critically ill adult patients

“…If the patient requires sedation, sedatives titrated to maintain a light, rather than deep, level of sedation (“conscious or cooperative sedation” in the FEPIMCTI guidelines) can be administered, unless clinically contraindicated. The Richmond Agitation‐Sedation Scale (RASS) and Sedation‐Agitation Scale are the most valid and reliable sedation assessment tools for measuring quality and depth of sedation in adult ICU patients, according to all three guidelines (evidence B) 11, 12. Both PAD guidelines recommend (grade +1B) routine use of either daily sedation interruption or a light target level of sedation for mechanically ventilated adult patients in the ICU.…”