Score sedation and agitation level using the Richmond Agitation-Sedation Scale (RASS) from +4 (combative) to −5 (unarousable) to guide analgo-sedation titration in ICU patients.
The Richmond Agitation-Sedation Scale (RASS) measures the level of sedation and agitation in ICU patients on a single −5 to +4 scale, from unarousable deep sedation to combative agitation. It is a bedside observational tool, not a laboratory value.
To gather the score, first observe the patient: if alert, restless, or agitated, assign 0 to +4. If not alert, call the patient's name and assign −1 to −3 based on eye opening and response. If there is no response to voice, apply physical stimulation and assign −4 to −5. Score the patient's best observed state during the assessment.
Interpret the result against the target range, typically −2 to 0 for most mechanically ventilated ICU patients. Scores of +1 to +4 indicate agitation and may warrant reassessment of sedation or analgesia; scores of −4 to −5 indicate deep sedation or unresponsiveness and carry a higher risk of oversedation.