What is the RASS score?

The RASS (Richmond Agitation-Sedation Scale) is a validated 10-point ordinal scale used in ICU settings to measure patient agitation and sedation level. Scores range from +4 (combative — violent, immediate danger to staff) to -5 (unarousable — no response to voice or physical stimulation). RASS 0 = alert and calm.

What RASS score is the ICU goal?

PADIS 2018 guidelines target RASS 0 to -2 (alert and calm to light sedation) for most mechanically ventilated ICU patients. Light sedation (RASS 0 to -2) is associated with fewer ventilator days, less delirium, shorter ICU stay, and lower mortality compared to deep sedation (RASS -3 to -5). Deeper targets may be appropriate for specific indications (status epilepticus, severe ARDS, elevated ICP).

How does RASS compare to Ramsay sedation scale?

RASS (10-point scale, +4 to -5) and Ramsay Scale (6-point scale, 1–6) are different tools with different value ranges — they cannot be converted to each other. PADIS 2018 guidelines recommend RASS (or SAS) rather than Ramsay Scale for routine ICU sedation monitoring due to superior reliability and wider clinical validation. Never interchange these scales in documentation.

What is the light sedation benefit in ICU patients?

Multiple RCTs (MENDS, SEDCOM, ABC trial, SPICE) demonstrate light sedation (RASS 0 to -2) vs. deep sedation (RASS -3 to -5) reduces: mechanical ventilation duration by 2–3 days, ICU length of stay by 3–4 days, delirium prevalence by 10–20%, and 6–12 month mortality. Light sedation is the standard of care in PADIS 2018 guidelines for most ICU patients.

What is the daily spontaneous awakening trial?

A daily spontaneous awakening trial (SAT) involves stopping all sedation infusions daily, allowing the patient to awaken to RASS 0 (fully alert). After awakening, a spontaneous breathing trial (SBT) is performed. The paired SAT + SBT (ABC Bundle, Girard et al. Lancet 2008) reduced ventilator days by 2.4 days and 1-year mortality by 14%. SAT is now standard care in most ICU sedation protocols.

Should RASS be documented when a patient is on paralytics?

No. Neuromuscular blocking agents (paralytics) eliminate motor responses, making RASS assessment meaningless — a fully awake patient would appear RASS -5. Do not document RASS in paralyzed patients. Instead, use EEG monitoring or BIS (bispectral index) to guide sedation depth. Target BIS 40–60 for adequate sedation during paralysis.

What RASS level is needed for extubation?

Extubation typically requires RASS 0 to -1 — the patient should be alert or drowsy but able to open eyes to voice, follow simple commands, cough on command, and have an adequate gag reflex. Patients at RASS -3 or deeper are generally not ready for extubation as they cannot protect the airway. Spontaneous breathing trials and extubation readiness assessment are performed at RASS 0 to -2.

What is RASS -4 vs -5 difference?

RASS -4 (deep sedation): patient has no response to verbal stimulation but DOES respond to physical stimulation (shoulder shaking or sternal rub) with any movement. RASS -5 (unarousable): patient has NO response to any stimulation — verbal or physical. Any movement, even non-purposeful, in response to physical stimulation = RASS -4, not -5.

Is RASS used for delirium assessment?

RASS is not a delirium tool — it measures arousal and sedation level. However, RASS is a required prerequisite for CAM-ICU delirium screening: RASS -4/-5 = unable to assess for delirium (document as 'UA — Unarousable'). RASS -3 to +4 = CAM-ICU can be performed. The two tools are complementary: RASS measures arousal; CAM-ICU screens for delirium within the arousal level that RASS defines.

Online Medical Tools — RASS Score

Printed on 9/4/2026

For informational purposes only. This is not medical advice.

Emergency

RASS Score

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.

RASS assessment

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How It Works

Observe patient behavior for 30 seconds

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.

Verbally stimulate the patient

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.

Physically stimulate the patient if no verbal response

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.

Who Uses the RASS Score

ICU Sedation Monitoring and Titration

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.

Daily Sedation Interruption Trials

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.

Ventilator Weaning Protocol Guidance

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.

CAM-ICU Prerequisite Assessment

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.

PADIS Guideline Compliance Monitoring

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.

Family Communication About Sedation Level

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.

Pro Tips

RASS is the recommended sedation tool in PADIS 2018 guidelines

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.

Target RASS 0 to -2 for most ICU patients — light sedation is preferred

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).

Deep sedation (RASS -3 to -5) independently increases mortality

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.

Daily SAT + SBT (ABC Bundle) reduces ventilator days by 2–3 days

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.

Assess PAIN before escalating sedation in agitated patients (RASS +1 to +4)

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.

Benzodiazepines are associated with more delirium than propofol or dexmedetomidine

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.

RASS +1 to +4: assess the cause before increasing sedation

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 has rapid on/off profile — preferred for titration

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).

Common Questions About Your Results

RASS -3 (moderate sedation): patient opens eyes or moves in response to voice — there is some response to verbal stimulus. RASS -4 (deep sedation): no response to voice — only responds to physical stimulation (shoulder shake or sternal rub) with movement. The key distinction is whether verbal stimulation alone produces any response. If calling the name loudly produces any eye movement or body movement, RASS -3 is more appropriate than -4.

A swing from deep sedation (RASS -4) to significant agitation (RASS +2) often indicates: SAT (daily awakening trial) in progress — expected behavior; rebound agitation after sedation lightening — assess for pain, anxiety, delirium; medication wearing off (propofol half-life 2–5 minutes, benzodiazepine half-life hours). Assess CPOT for pain, CAM-ICU for delirium, and address the underlying cause before re-sedating.

Evidence-Based Methodology

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).

Clinical Content Trust

Last reviewed:: April 21, 2026
Guideline version:: General evidence framework v2026.04
Source set version:: Primary-source set v1

How to Interpret Your Result

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.

When to Use This Tool

Use RASS during emergency and ICU care whenever monitoring mental arousal, titrating sedatives, or documenting agitation trends over time.

Limitations

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.

Changelog

April 21, 2026 · trust-baseline
Clinical trust metadata enabled for this tool page with structured review/version fields.

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Frequently Asked Questions

+4 Combative (violent, dangerous); +3 Very agitated (pulling tubes, aggressive); +2 Agitated (frequent non-purposeful movement, fighting ventilator); +1 Restless (anxious, apprehensive); 0 Alert and calm; -1 Drowsy (briefly awakens >10 sec); -2 Light sedation (briefly awakens <10 sec); -3 Moderate sedation (movement to voice, no eye contact); -4 Deep sedation (movement to physical stimulus only); -5 Unarousable (no response to any stimulus).

Three-step process: (1) Observe for spontaneous agitation 30 seconds — if yes, assign RASS +1 to +4. (2) If no spontaneous agitation: call name, ask to open eyes — sustained eye opening >10 sec = RASS 0; brief <10 sec = RASS -1; movement without eye contact = RASS -2. (3) If no verbal response: physical stimulation (shoulder shake/sternal rub) — movement = RASS -3 or -4; no response = RASS -5.

Online Medical Tools — RASS Score

RASS Score

How It Works

Observe patient behavior for 30 seconds

Verbally stimulate the patient

Physically stimulate the patient if no verbal response

Who Uses the RASS Score

ICU Sedation Monitoring and Titration

Daily Sedation Interruption Trials

Ventilator Weaning Protocol Guidance

CAM-ICU Prerequisite Assessment

PADIS Guideline Compliance Monitoring

Family Communication About Sedation Level

Pro Tips

RASS is the recommended sedation tool in PADIS 2018 guidelines

Target RASS 0 to -2 for most ICU patients — light sedation is preferred

Deep sedation (RASS -3 to -5) independently increases mortality

Daily SAT + SBT (ABC Bundle) reduces ventilator days by 2–3 days

Assess PAIN before escalating sedation in agitated patients (RASS +1 to +4)

Benzodiazepines are associated with more delirium than propofol or dexmedetomidine

RASS +1 to +4: assess the cause before increasing sedation

Propofol has rapid on/off profile — preferred for titration

Common Questions About Your Results

Evidence-Based Methodology

Clinical Content Trust

How to Interpret Your Result

When to Use This Tool

Limitations

Changelog

Related Tools

CAM-ICU

Glasgow Coma Scale

SOFA Score

APACHE II Score

Further Reading

A Complete Guide to Emergency Medicine: Decision Tools, Scoring Systems, and Clinical Protocols

Frequently Asked Questions