RASS Score and its use in the Retrieval Setting

Author: Brian Halse

The Richmond Agitation-Sedation Scale (RASS)

The Richmond Agitation-Sedation Scale (RASS) is a tool used to assess a patient’s level of agitation or sedation, particularly in intensive care units (ICUs) or other critical care settings where sedation management is crucial.

The scale helps healthcare providers evaluate whether a patient is appropriately sedated or if adjustments are needed to their sedation plan. It differs from other scales that assess level of consciousness, like the GCS, but rather only assesses level of agitation or sedation.

This scale is not ideal for a patient who has received long term paralytics - and this should always be taken into account when choosing sedation and analgesia options for the patient who is paralysed (they will be unable to respond and show physical signs of poor sedation or analgesia).

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Richmond Agitation-Sedation Scale (RASS):

The RASS is divided into two main categories:

- Agitation Levels: These levels indicate varying degrees of agitation and restlessness.

- Sedation Levels: These levels indicate varying degrees of sedation

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Scoring Categories:

+4 (Combative): The patient is overtly combative, violent, and poses an immediate danger to themselves or others. They are unable to cooperate with the assessment.

?+3 (Very Agitated): The patient is very restless and anxious. They are pulling at the tubes, trying to climb out of bed, or exhibiting similar behavior.

+2 (Agitated): The patient is agitated but not as extreme as in +3 or +4. They are fidgety or uneasy but can be calmed down.

+1 (Restless): The patient is restless, but their behavior is not disruptive or dangerous. They may be moving around or showing slight discomfort.

0 (Alert and Calm): The patient is calm and alert, oriented, and cooperative?

-1 (Drowsy): The patient is drowsy but can be aroused briefly to answer questions or respond to stimuli. They fall back asleep once the stimulus is removed.

-2 (Light Sedation): The patient is easily aroused but may be minimally responsive to verbal stimuli. They might have a delayed response.

?-3 (Moderate Sedation): The patient is difficult to arouse and responds only to repeated or loud verbal stimuli or physical stimulation.

-4 (Deep Sedation): The patient is only arousable with physical stimulation and may not respond appropriately or in a timely manner.

-5 (Unarousable): The patient does not respond to any form of stimulation. They are completely unresponsive and may be ????? unconscious.

How to Use the RASS:

Assessment:

The healthcare provider evaluates the patient’s responsiveness and agitation level by attempting to arouse them and observing their behaviour.

?Scoring:

Based on the patient’s response, the provider assigns a score from +4 to -5.

Intervention:

The score helps guide decisions about sedation levels, ensuring the patient is neither over-sedated nor under-sedated. It helps in managing sedation effectively, avoiding complications such as excessive sedation or agitation. Your intention needs to be very clear when deciding on what medication to administer - and at what doses.

Monitoring:

Regular use of the RASS can help track changes in the patient’s sedation level over time and adjust treatment as needed.

?Advantages of RASS:

- Simplicity: The scale is straightforward and easy to use.

- Standardization: Provides a standardized way to assess and communicate sedation levels.

- Flexibility: Useful in a variety of clinical settings and with different patient populations.

The RASS is a valuable tool for managing sedation and ensuring patient comfort and safety in clinical environments and should be used to assess all sedated patients continuously and their level of sedation adjusted to meet the lowest sedation to keep the patient calm and comfortable, preferably rousable, but in some instance3d deep sedation may be required in the HEMS environment. This tool does not replace the GCS but rather complements its assessment providing an assessment of the patient's sedation level rather than consciousness level.

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References:

Chulay, Marianne. (2004). Sedation assessment: easier said than done!,

Critical Care Nursing Clinics of North America,

16: 3, ?pp359-364, ISSN 0899-5885,

https://doi.org/10.1016/j.ccell.2004.04.006.

Dawson, Rachel & Fintel, Nicholas & Nairn, Stuart. (2010). Sedation assessment using the Ramsay scale. Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association. 18. 18-20. 10.7748/en2010.06.18.3.18.c7825.

Kerson AG, DeMaria R, Mauer E, Joyce C, Gerber LM, Greenwald BM, Silver G, Traube C. Validity of the Richmond Agitation-Sedation Scale (RASS) in critically ill children. J Intensive Care. 2016 Oct 26;4:65. doi: 10.1186/s40560-016-0189-5. PMID: 27800163; PMCID: PMC5080705.