RASS, Richmond Agitation-Sedation Scale
Range from +4 to -5. Most protocols target 0 to -2, and delirium can be assessed down to -3.
Updated · Methodology
The assessment follows an order: observation first, then voice, then physical stimulation.
About this calculator
The assessment follows a strict order: observe the patient first, then call them by name and ask them to open their eyes, and only then apply a physical stimulus. The order is not a formality: starting with a physical stimulus leaves nothing to separate levels -1 through -3, since those differ precisely by the response to voice and the duration of eye contact. The practical value of the scale sits at two points. First, a RASS of -3 or above allows delirium assessment with CAM-ICU, while at -4 and -5 assessment is impossible and the patient counts as unable to be tested. Second, the 0 to -2 target range in current protocols is maintained with light sedation, because deeper sedation is associated with longer ventilation and hospital stay. Positive values call for their own workup. Agitation in an intensive care patient more often follows pain, hypoxia, urinary retention, or alcohol or benzodiazepine withdrawal, and deepening sedation without looking for the cause masks the problem instead of solving it.
Source
Formula version: sessler-2002-v1
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