Richmond Agitation-Sedation Scale (RASS)
Standardised sedation and agitation scale for ICU patients. Range −5 (unarousable) to +4 (combative). Used to titrate sedation and assess readiness for awakening trials. Target RASS 0 to −2 for most ventilated patients.
Score interpretation
RASS +1 to +4: Agitation. Risk of self-extubation, line removal, and harm to staff.
→ Assess and treat reversible causes (pain, delirium, hypoxia, urinary retention, constipation). Analgesia-first approach (A1C). Consider titrating sedoanalgesia. Target RASS 0 to −2 for ventilated ICU patients.
RASS 0: Alert and calm. Optimal state for most non-ventilated ICU patients and spontaneous breathing trials.
→ Maintain current management. Reassess regularly. Ideal for spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT).
RASS −1 to −2: Light sedation. Accepted sedation target for mechanically ventilated ICU patients (PADIS 2018 guidelines).
→ Appropriate level. Continue current regimen. Perform daily SAT. Reassess daily need for sedation. Aim to wean as tolerated.
RASS −3 to −4: Deep sedation. Associated with prolonged mechanical ventilation, ICU delirium, and increased mortality.
→ Consider reducing sedation unless clinically indicated (raised ICP, prone positioning, status epilepticus, severe dyssynchrony). Reassess sedation protocol. Avoid benzodiazepine infusions where possible.
RASS −5: Unarousable. Consider drug-induced coma versus neurological catastrophe.
→ Urgent neurological assessment. Exclude intracerebral event (haemorrhage, oedema). Consider CT head if unexplained. Review all sedating medications. Perform EEG if seizure suspected.
Interpretation bands for the RASS. Apply clinical judgement and local guidance.
References
- Sessler CN et al. The Richmond Agitation-Sedation Scale. Am J Respir Crit Care Med. 2002;166(10):1338–1344.
- Devlin JW et al. Clinical Practice Guidelines for Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult ICU Patients (PADIS). Crit Care Med. 2018.
Related
Curated clinical cross-links plus same-class fallbacks.
- Propofol · Anaesthetic (IV Induction / Sedation)
- Ketamine (Anaesthesia/Sedation) · Dissociative Anaesthetic (NMDA Receptor Antagonist)
- Remimazolam · Ultra-Short Acting Benzodiazepine (Procedural Sedation)
- Haloperidol (Delirium) · Typical Antipsychotic (Butyrophenone)
- Midazolam (Paediatric) · Benzodiazepine — Status Epilepticus (First-Line) / Procedural Sedation
- Ketamine · Dissociative Anaesthetic / Procedural Sedation
- Difficult Airway Algorithm (DAS) · DAS 2015; Royal College of Anaesthetists
- Major Haemorrhage Protocol · NICE NG24; UK MHP guidelines
- New-Onset Atrial Fibrillation · ESC 2020 AF Guidelines; NICE NG196
- Hypertensive Emergency · ESC/ESH 2018 Hypertension Guidelines; NICE NG136
- Bradycardia Management · Resuscitation Council UK ABCDE; ESC 2021 Pacing Guidelines
- Ventricular Tachycardia / Fibrillation · Resuscitation Council UK ACLS; ESC 2022 Ventricular Arrhythmia Guidelines
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.