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Printed on 7/20/2026
For informational purposes only. This is not medical advice.
The Richmond Agitation-Sedation Scale (RASS) is a standard ICU and emergency-care scale for quantifying mental arousal from severe agitation to deep sedation. It supports sedation titration, delirium workflows, and communication during serial neurologic checks.
Formula: Single-item ordinal scale from +4 (combative) to -5 (unarousable), based on bedside response to voice and physical stimulation.
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Begin RASS assessment by observing the patient for 30 seconds without stimulation. Document if spontaneous agitation behaviors are present: +4 = combative (violent, immediate danger to staff); +3 = very agitated (pulling lines/tubes, aggressive); +2 = agitated (frequent non-purposeful movement, fighting ventilator); +1 = restless (anxious, apprehensive, movements not aggressive). If none of these apply, proceed to the next step.
Call the patient's name and ask them to 'open your eyes and look at me.' Assess the response: sustained eye opening with eye contact >10 seconds = RASS 0 (alert and calm); eye opening with brief eye contact <10 seconds = RASS -1 (drowsy); any eye opening or movement to voice but no eye contact = RASS -2 (light sedation). If there is no response to verbal stimulation, proceed to physical stimulation.
Apply physical stimulation: shoulder shaking or sternal rub. Any movement in response = RASS -3 (moderate sedation) or RASS -4 (deep sedation — differentiate by whether movement is purposeful toward stimulus vs. non-purposeful). Absolutely no response to physical stimulation = RASS -5 (unarousable). Document and communicate RASS value.
ICU nurses
RASS is used every 2–4 hours (or per institutional protocol) to guide sedation titration to the target range (typically RASS 0 to -2). If RASS is deeper than target (e.g., -4 when targeting -2), reduce sedation infusion rate. If agitated (RASS +2), assess for pain first, then consider sedation increase or agent change.
Intensivists
Daily spontaneous awakening trials (SAT) target RASS 0 — stopping sedation infusions to allow full arousal. RASS measures the depth of sedation before SAT initiation and tracks arousal during and after the trial. SAT paired with spontaneous breathing trials (SBT) reduces ventilator days and ICU length of stay.
Respiratory therapists
Successful ventilator weaning and extubation requires appropriate level of consciousness. RASS 0 to -1 is typically required for extubation readiness — the patient should be awake enough to protect the airway and follow commands. Patients at RASS -3 or deeper typically cannot be extubated safely.
ICU teams
RASS is always assessed before CAM-ICU. RASS -4/-5 = CAM-ICU cannot be performed. RASS -3 to +4 = CAM-ICU can be attempted. Documenting RASS alongside CAM-ICU provides complete sedation and delirium status in a single clinical entry.
Quality improvement teams
PADIS 2018 guidelines recommend targeting light sedation (RASS 0 to -2) in most ICU patients. Quality monitoring of documented RASS values and percent time at target sedation level is a key ICU quality metric. Regular RASS documentation audits identify sedation depth deviations and guideline compliance.
Bedside nurses
RASS provides families with objective, standardized information about sedation level. 'Your family member is at RASS -2 — they briefly open their eyes when we call their name' is more precise and reassuring than 'they're sedated.' Communicating RASS trajectory (improving toward 0) conveys clinical progress.
PADIS 2018 guidelines (Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption) recommend RASS and SAS (Sedation Agitation Scale) as the two validated sedation scales for routine ICU use. RASS has a 10-point scale (+4 to -5) compared to SAS's 7-point scale (1–7), providing finer gradation in sedation depth.
Multiple trials (MENDS, SEDCOM, ABC trial) demonstrate that light sedation (RASS 0 to -2) compared to deep sedation (RASS -3 to -5) reduces ventilator days, ICU length of stay, delirium duration, and mortality. Target RASS 0 to -2 unless there is a specific indication for deeper sedation (status epilepticus, ARDS with neuromuscular blockade, severe ICP elevation).
Shehabi et al. (JAMA 2012, SPICE study) demonstrated early deep sedation (RASS -3 or deeper within 48 hours of ICU admission) was independently associated with increased 180-day mortality after adjustment for severity. Every additional day of deep sedation increases mortality risk. Avoid deep sedation unless specifically indicated.
Girard et al. (Lancet 2008, ABC trial) showed daily spontaneous awakening trials (SAT, targeting RASS 0) paired with spontaneous breathing trials (SBT) reduced time on ventilator by 2.4 days, ICU stay by 3.2 days, and 1-year mortality by 14%. This is the strongest evidence-based intervention in ICU sedation management.
Pain is one of the most common causes of agitation in ICU patients. Before increasing sedation in a RASS +1 or higher patient, always assess and treat pain first (CPOT assessment, analgesia trial). The analgesia-first approach reduces sedation requirements, delirium, and total opioid doses. Treating agitation with sedation before addressing pain is a common and harmful error.
Multiple observational and RCT data show benzodiazepine-based sedation (lorazepam, midazolam) is associated with significantly higher rates of ICU delirium compared to propofol or dexmedetomidine. Dexmedetomidine allows cooperative, arousable sedation (RASS 0 to -2) with analgesic properties, less respiratory depression, and fewer delirium-positive days in MENDS trial.
Agitation causes to rule out before adding/increasing sedation: pain (CPOT), urinary retention (bladder scan), ventilator dyssynchrony (check ventilator settings, adjust flow/trigger), medications (akathisia from metoclopramide, steroids, dopamine agonist withdrawal), hypoglycemia, hypoxia, hypercarbia. Address the cause — don't reflexively sedate agitation.
Propofol infusion has a rapid onset and short half-life enabling minute-to-minute RASS titration. It also allows clear cognitive windows during daily SAT. Disadvantages: hypotension at higher doses, propofol infusion syndrome (rare, >5 mg/kg/hr for >48h), hypertriglyceridemia. Not recommended for patients requiring enteral nutrition (caloric content).
RASS published by Sessler et al. (Am J Respir Crit Care Med 2002) from 290 adult ICU patients. Inter-rater reliability ICC 0.956; validity against GCS and Ramsay Scale. PADIS Guidelines (Devlin et al., Crit Care Med 2018): RASS and SAS are recommended for routine ICU sedation monitoring. Deep sedation (RASS -3 to -5) and mortality: Shehabi et al. (JAMA 2012). ABC Bundle for ventilator liberation: Girard et al. (Lancet 2008).
Positive RASS values indicate agitation severity, zero reflects alert calm status, and negative values indicate progressively deeper sedation. Very negative scores can limit neurologic assessment and delirium screening reliability.
Use RASS during emergency and ICU care whenever monitoring mental arousal, titrating sedatives, or documenting agitation trends over time.
RASS is observer-based and can vary by examiner technique. It reflects arousal state at one point in time and does not independently diagnose pain, delirium etiology, or neurologic injury.
Disclaimer: This tool is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about your health.
April 21, 2026 · trust-baseline
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