Richmond Agitation-Sedation Scale (RASS)

Use the RASS calculator to assess agitation and sedation depth in ICU patients. A 10-level bedside scale from +4 (combative) to -5 (unarousable) endorsed by the 2018 PADIS guidelines for sedation monitoring in critically ill adults.

Richmond Agitation-Sedation Scale (RASS)

Select the level that best describes the patient's current behavior. Observe first; if the patient is not alert, use verbal then physical stimulation per the stepwise RASS procedure.

Agitation levels

Observation: patient is alert, restless, or agitated

Baseline

Observation: patient is alert and calm

Sedation levels

If not alert: call patient by name, ask to open eyes and look at speaker (verbal stimulation). If no response to voice, physically stimulate (shoulder shake or sternal rub).

Disclaimer: The RASS is an educational clinical assessment tool. It does not replace bedside clinical judgment or institutional sedation protocols. Sedation targets should be individualized based on the patient's clinical condition, treatment goals, and institutional guidelines. Always consult relevant clinical protocols and specialist expertise.

Richmond Agitation-Sedation Scale (RASS): scoring procedure, levels, and clinical context

Overview

The Richmond Agitation-Sedation Scale (RASS) is a 10-level clinician-assessed scale ranging from +4 (combative) to -5 (unarousable) that quantifies a patient's level of agitation or sedation. It was developed in 2002 at Virginia Commonwealth University through collaboration among critical care physicians, nurses, and pharmacists. The RASS has demonstrated excellent inter-rater reliability (weighted kappa 0.91-0.94) and construct, criterion, and face validity in medical/surgical ICU populations, including both mechanically ventilated and non-ventilated patients.

Stepwise scoring procedure

The RASS is scored using a three-step hierarchical approach, moving from observation to verbal stimulation to physical stimulation only if needed:

Step 1: Observation (30 seconds)

Observe the patient without interacting. If the patient is alert, restless, agitated, or combative, score 0 to +4 based on the observed behavior.

Step 2: Verbal stimulation

If the patient is not alert (does not spontaneously meet criteria for 0 to +4), call the patient by name and say "Open your eyes and look at me." Score based on the response:

-1: Awakens with sustained (>10 sec) eye opening and eye contact
-2: Awakens with brief (<10 sec) eye opening and eye contact
-3: Any movement to voice (e.g., eye opening) but no eye contact

Step 3: Physical stimulation

If there is no response to verbal stimulation, physically stimulate the patient (shoulder shake and/or sternal rub):

-4: Any movement to physical stimulation (but not to voice)
-5: No response to voice or physical stimulation

Complete RASS scale

Score	Term	Description
+4	Combative	Overtly combative or violent; immediate danger to staff
+3	Very Agitated	Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff
+2	Agitated	Frequent nonpurposeful movement or patient-ventilator dyssynchrony
+1	Restless	Anxious or apprehensive but movements not aggressive or vigorous
0	Alert and Calm	Spontaneously pays attention to caregiver
-1	Drowsy	Not fully alert, but has sustained (>10 sec) awakening, with eye contact, to voice
-2	Light Sedation	Briefly (<10 sec) awakens with eye contact to voice
-3	Moderate Sedation	Any movement (but no eye contact) to voice
-4	Deep Sedation	No response to voice, but any movement to physical stimulation
-5	Unarousable	No response to voice or physical stimulation

Sedation target guidelines

The 2018 PADIS (Pain, Agitation/sedation, Delirium, Immobility, and Sleep disruption) guidelines from the Society of Critical Care Medicine recommend:

RASS target	Indication
0 to -2	Light sedation: recommended for most mechanically ventilated adults. Associated with shorter ventilation duration, reduced ICU length of stay, and lower delirium incidence.
-3 to -5	Deep sedation: may be appropriate when clinically indicated (e.g., neuromuscular blockade, prone positioning, severe ARDS, refractory intracranial hypertension, status epilepticus, acute severe alcohol withdrawal). Document clinical justification.

RASS and delirium screening

The RASS is a prerequisite component of the Confusion Assessment Method for the ICU (CAM-ICU). Before performing a CAM-ICU delirium assessment, the clinician first scores the RASS:

RASS -4 or -5: Patient is too deeply sedated for delirium assessment. Reassess later when lighter sedation is achieved. The CAM-ICU cannot be performed.
RASS -3 to +4: Proceed with CAM-ICU assessment. Delirium can be present at any RASS level in this range. Hypoactive delirium (RASS -3 to 0 with positive CAM-ICU) is common and easily missed.

Validity and reliability

Inter-rater reliability: Weighted kappa 0.91 (nurse-nurse), 0.94 (nurse-other), indicating excellent agreement.
Criterion validity: High correlation with the Sedation-Agitation Scale (SAS; r = 0.78) and visual analog scale for sedation (r = -0.79 to -0.83).
Construct validity: Significant correlation with Glasgow Coma Scale (GCS; r = 0.91) and changes in level of consciousness scores (r = 0.84).
Face validity: 92% of ICU nurses rated the RASS as easy to use after brief training.
Populations studied: Validated in medical, surgical, and cardiac ICU patients, both ventilated and non-ventilated.

Comparison with other sedation scales

Feature	RASS	SAS	Ramsay
Range	-5 to +4 (10 levels)	1 to 7 (7 levels)	1 to 6 (6 levels)
Anchor point	0 = Alert and calm	4 = Calm and cooperative	2 = Cooperative, oriented
Sedation granularity	5 levels (-1 to -5)	3 levels (1 to 3)	4 levels (3 to 6)
Agitation granularity	4 levels (+1 to +4)	3 levels (5 to 7)	1 level (1)
CAM-ICU compatible	Yes (required)	Yes (adaptable)	Not standard

Key references

Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338-1344.
Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003;289(22):2983-2991.
Devlin JW, Skrobik Y, Gelinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825-e873.
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.

Practice caveats

The RASS assesses the level of arousal and agitation but does not diagnose the cause. Always evaluate for underlying etiologies (pain, delirium, hypoxia, drug effects, metabolic derangements) before adjusting sedation.
RASS scores should be documented at regular intervals (typically every 4 hours, or more frequently during sedation titration) and whenever there is a clinically significant change in the patient's condition.
Deep sedation (RASS -4 to -5) when not clinically indicated is associated with increased delirium incidence, longer mechanical ventilation, and higher mortality. The PADIS guidelines recommend light sedation (RASS 0 to -2) for most ICU patients.
The RASS has not been extensively validated in pediatric populations. For children, consider age-appropriate sedation scales such as the State Behavioral Scale (SBS) or COMFORT-B.

Introduction

Effective management of sedation and agitation is a cornerstone of intensive care medicine. Critically ill patients frequently require sedative and analgesic medications to tolerate invasive procedures, mechanical ventilation, and the stressful ICU environment. However, both over-sedation and under-sedation carry significant clinical consequences. Over-sedation prolongs mechanical ventilation, increases the incidence of delirium, promotes ICU-acquired weakness, and extends hospital length of stay. Under-sedation, by contrast, leads to patient distress, self-extubation, device removal, hemodynamic instability, and risk of harm to caregivers.

The Richmond Agitation-Sedation Scale (RASS) was developed to address the need for a reliable, reproducible, and clinically practical tool that quantifies the spectrum from severe agitation to deep unresponsiveness. Since its introduction in 2002, the RASS has become one of the most widely adopted sedation assessment instruments in adult intensive care units worldwide. Its acceptance is underpinned by rigorous validation data, endorsement by major critical care guidelines, and its suitability for integration into broader ICU assessment bundles that simultaneously address pain, agitation, delirium, immobility, and sleep disruption.

Historical Context and Development

Prior to the RASS, several sedation scales existed, including the Ramsay Sedation Scale (RSS), the Sedation-Agitation Scale (SAS), and the Motor Activity Assessment Scale (MAAS). While each contributed to the evolution of bedside sedation monitoring, they had notable limitations. The Ramsay scale, introduced in 1974, was among the earliest but lacked granularity at the agitation end of the spectrum and demonstrated variable inter-rater reliability in subsequent evaluations. The SAS offered improved agitation descriptors but was less discriminative in the lighter sedation range.

Recognizing these gaps, a multidisciplinary team at Virginia Commonwealth University led by Sessler, Gosnell, Grap, and colleagues set out to create a sedation scale that would span the full agitation-sedation continuum with clearly differentiated levels, employ observable behavioral anchors amenable to systematic bedside assessment, demonstrate strong inter-rater reliability among nurses, physicians, and pharmacists, and correlate with objective physiological measures. The result was the RASS, published in the American Journal of Respiratory and Critical Care Medicine in 2002. A subsequent validation study by Ely and colleagues in 2003 confirmed its reliability and validity in a broader population, including medical ICU patients at Vanderbilt University.

Scale Structure and Scoring

The RASS is a 10-level ordinal scale that ranges from +4 (most agitated) to -5 (most deeply sedated), with 0 representing an alert and calm baseline. The scale is divided into three functional domains:

Agitation Levels (+1 to +4)

Score	Term	Description
+4	Combative	Overtly combative or violent; immediate danger to staff
+3	Very Agitated	Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff
+2	Agitated	Frequent nonpurposeful movement or patient-ventilator dyssynchrony
+1	Restless	Anxious or apprehensive but movements not aggressive or vigorous

Baseline Level (0)

Score	Term	Description
0	Alert and Calm	Spontaneously pays attention to caregiver

Sedation Levels (-1 to -5)

Score	Term	Description
-1	Drowsy	Not fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice
-2	Light Sedation	Briefly (less than 10 seconds) awakens with eye contact to voice
-3	Moderate Sedation	Any movement (but no eye contact) to voice
-4	Deep Sedation	No response to voice, but any movement to physical stimulation
-5	Unarousable	No response to voice or physical stimulation

A key design feature of the RASS is the distinction between eye contact and mere movement, particularly at levels -1 through -3. This distinction provides a clinically meaningful gradient: eye contact to voice indicates cortical processing and purposeful arousal, whereas movement without eye contact suggests a more reflexive, subcortical response. This granularity allows clinicians to titrate sedation with greater precision than scales that rely on broader categories.

Stepwise Bedside Assessment Procedure

The RASS employs a standardized three-step assessment method designed to be completed in under 30 seconds. Consistency in applying this procedure is essential for reliable scoring.

Step 1: Observation

The clinician observes the patient for 30 seconds without direct interaction. If the patient is alert, making eye contact, and appears calm, the score is RASS 0. If the patient is moving restlessly, appears anxious, or is exhibiting nonpurposeful movements, aggressive behavior, or combativeness, the corresponding agitation score (+1 through +4) is assigned based on the descriptors above. If the patient appears to be asleep or has eyes closed, proceed to Step 2.

Step 2: Verbal Stimulation

The clinician calls the patient by name in a normal speaking voice and instructs them: "Open your eyes and look at me." If the patient does not respond to this initial verbal cue, the instruction is repeated more loudly. The clinician assesses whether eye opening and eye contact occur and, if so, for how long they are sustained:

Sustained eye contact for more than 10 seconds: RASS -1
Brief eye contact lasting less than 10 seconds: RASS -2
Any movement (limb, head) in response to voice but no eye contact: RASS -3
No response to voice: Proceed to Step 3

Step 3: Physical Stimulation

If the patient does not respond to verbal stimulation, the clinician applies physical stimulation. The recommended method is a trapezius squeeze (grasping the trapezius muscle between thumb and fingers and squeezing firmly) or a sternal rub. The response is evaluated as follows:

Any movement to physical stimulation: RASS -4
No response to physical stimulation: RASS -5

This hierarchical approach (observation first, then voice, then physical touch) minimizes unnecessary stimulation, which is particularly important for patients at light sedation targets where repeated arousal can impair sleep quality and recovery.

Psychometric Properties and Validation

The RASS has been subjected to extensive psychometric evaluation across multiple ICU populations. In the original 2002 validation study by Sessler and colleagues, the scale demonstrated high inter-rater reliability (weighted kappa = 0.91 among nurses, 0.94 among nurse-physician pairs, and 0.93 among nurse-pharmacist pairs). It also showed excellent face validity and content validity, as the descriptors were developed through an iterative process involving nurses, physicians, and pharmacists with ICU expertise.

Construct validity was assessed through correlation with visual analog scale (VAS) sedation assessments, Glasgow Coma Scale (GCS) scores, and level of consciousness measured by bispectral index (BIS) monitoring. The RASS showed significant correlations with all three measures, supporting its construct validity as a measure of the agitation-sedation continuum.

The 2003 validation study by Ely and colleagues at Vanderbilt confirmed these findings in an independent medical ICU cohort and demonstrated that the RASS had superior discriminative ability compared to the Ramsay Sedation Scale, particularly in differentiating levels of light sedation. Importantly, the RASS was validated in both mechanically ventilated and non-ventilated patients, broadening its applicability.

Subsequent studies have replicated these reliability findings in diverse settings, including surgical ICUs, cardiac ICUs, neurological ICUs, burn units, and emergency departments. The scale has also been validated in non-English-speaking populations through translation and cultural adaptation studies.

Guideline-Directed Sedation Targets

The 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS guidelines), published jointly by the Society of Critical Care Medicine (SCCM), represent the current evidence-based standard for ICU sedation management. These guidelines provide strong recommendations regarding sedation depth and monitoring:

Light Sedation Over Deep Sedation

The PADIS guidelines recommend using light sedation (RASS 0 to -2) rather than deep sedation for most critically ill, mechanically ventilated adults. This recommendation is supported by multiple randomized controlled trials and meta-analyses demonstrating that light sedation strategies are associated with shorter duration of mechanical ventilation, earlier extubation, reduced ICU length of stay, lower incidence of delirium, and no increase in adverse events such as self-extubation or unplanned device removal when adequate monitoring is in place.

Validated Sedation Scales

The PADIS guidelines recommend using a validated sedation assessment tool (specifically the RASS or the SAS) over subjective clinical assessment to monitor sedation depth. They note that the RASS and SAS have the strongest psychometric data supporting their use in adult ICU patients.

Daily Sedation Interruption and Awakening Trials

Coupled with light sedation targets, the guidelines endorse daily sedation interruption (DSI) or spontaneous awakening trials (SAT) as strategies to minimize sedative exposure. During an SAT, sedative infusions are paused and the patient is assessed for agitation. The SAT is commonly paired with a spontaneous breathing trial (SBT) in the "wake up and breathe" protocol, which has been shown to reduce ventilator days and mortality. The RASS serves as the primary tool for evaluating tolerance of sedation interruption: a patient who reaches RASS 0 to -1 without significant agitation during the trial has demonstrated readiness for continued minimized sedation.

Individualized Targets

While light sedation is the default target, certain clinical scenarios warrant deeper sedation. These include patients receiving neuromuscular blocking agents (who require a minimum RASS of -4 to -5 for patient safety and comfort), patients with refractory intracranial hypertension requiring burst suppression, patients undergoing therapeutic hypothermia, patients with severe acute respiratory distress syndrome (ARDS) on prone positioning who require deep sedation for safety, and patients with refractory status epilepticus. In these cases, the RASS target should be clearly documented, and the need for deep sedation should be reassessed at least daily.

Integration with Delirium Monitoring

The RASS is intrinsically linked to delirium assessment in the ICU. The Confusion Assessment Method for the ICU (CAM-ICU), one of the two delirium screening tools recommended by the PADIS guidelines, requires a RASS score of -3 or higher for the assessment to be performed. Patients at RASS -4 or -5 are too deeply sedated for a meaningful delirium evaluation; they are documented as "unable to assess" and reassessed once they reach a lighter sedation level.

This integration has important clinical implications. Deep sedation itself is a strong independent risk factor for the development of delirium. By maintaining patients at lighter sedation targets (RASS 0 to -2), clinicians not only enable accurate delirium screening but also reduce the substrate that promotes delirium. The ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment) explicitly incorporates RASS-guided sedation and CAM-ICU delirium screening as complementary components of a unified evidence-based care pathway.

RASS in Special Populations

Pediatric Patients

The standard RASS was developed and validated in adult ICU populations. For pediatric patients, age-appropriate modifications exist, including the State Behavioral Scale (SBS) and the COMFORT-B scale. Some institutions have adapted the RASS for older children and adolescents, but the behavioral anchors (particularly at the sedation levels) may not be appropriate for neonates and young infants whose baseline behavioral repertoire differs from adults.

Neurological Patients

In patients with primary neurological injury (e.g., traumatic brain injury, ischemic stroke, intracerebral hemorrhage), the RASS may be less discriminative because alterations in consciousness may be due to the underlying neurological condition rather than sedation. In these patients, the RASS should be interpreted alongside the GCS and a focused neurological examination. A "worsening" RASS score in a neurological patient should prompt evaluation for new neurological events (e.g., rebleeding, cerebral edema, seizures) rather than automatic sedation adjustment.

Patients Receiving Neuromuscular Blocking Agents

Patients who are pharmacologically paralyzed cannot exhibit the behavioral responses that the RASS relies upon. In this setting, the RASS cannot be reliably assessed, and supplementary monitoring such as the bispectral index (BIS) or processed electroencephalography may be considered to ensure adequate sedation during paralysis. The PADIS guidelines suggest monitoring sedation depth with EEG-based tools when neuromuscular blocking agents are used for extended periods.

Common Pitfalls and Practical Considerations

Inconsistent Assessment Technique

One of the most common sources of RASS scoring variability is failure to follow the standardized stepwise assessment procedure. Skipping the observation period, combining verbal and physical stimulation simultaneously, or failing to time the duration of eye contact at the -1 and -2 distinction point all introduce measurement error. Ongoing nursing education and periodic competency validation are essential for maintaining inter-rater reliability.

Confounding by Pain

Uncontrolled pain can present as agitation, leading to elevated RASS scores that may be misinterpreted as a need for more sedation rather than more analgesia. The PADIS guidelines emphasize an "analgesia-first" approach: assessing and treating pain (using validated tools such as the Critical-Care Pain Observation Tool or the Behavioral Pain Scale) before escalating sedative doses. Addressing pain often reduces agitation and allows the patient to reach the target RASS without excessive sedation.

Documentation and Trending

A single RASS assessment provides a snapshot of the patient's sedation level at one point in time. Clinically meaningful sedation management requires regular, serial assessments (typically every 2 to 4 hours and before and after sedation adjustments) with documentation that allows trend analysis. Electronic health record integration can facilitate graphical display of RASS trends alongside sedative infusion rates, enabling clinicians to identify patterns such as over-sedation during overnight hours or agitation spikes around nursing care activities.

Inter-Shift Handoff

Including the sedation target (e.g., "RASS target 0 to -1") and the most recent assessed RASS score in bedside handoff communications ensures continuity of sedation goals between providers. A clear, agreed-upon target reduces the risk of sedation creep, where incremental dose increases during a shift result in deeper-than-intended sedation over time.

Role in Sedation Protocols and Quality Improvement

Many ICUs have implemented nurse-driven sedation protocols in which bedside nurses titrate sedative infusions to a physician-specified RASS target. These protocols typically follow an algorithm: assess RASS, compare to target, titrate infusion rate up or down in predefined increments, and reassess. Protocol-based sedation using the RASS has been associated with reduced sedative consumption, shorter ventilator days, and decreased ICU length of stay in before-and-after studies and quality improvement initiatives.

The RASS is also used as a quality metric in ICU benchmarking programs. Percentage of time spent at the target RASS range, time spent in deep sedation (RASS -3 or deeper) without a documented clinical indication, and frequency of RASS assessments are measurable indicators that can be tracked and improved through structured quality initiatives. Institutions participating in collaborative improvement networks (such as the ICU Liberation Collaborative) have reported significant improvements in sedation-related outcomes by standardizing RASS-based assessment and targeting.

Comparison with Other Sedation Scales

Several sedation scales are in clinical use, and the RASS is often compared to the Sedation-Agitation Scale (SAS), Ramsay Sedation Scale (RSS), and the Motor Activity Assessment Scale (MAAS).

Feature	RASS	SAS	Ramsay
Range	-5 to +4	1 to 7	1 to 6
Levels	10	7	6
Agitation granularity	4 levels	3 levels	1 level
Sedation granularity	5 levels	3 levels	4 levels
Standardized procedure	Yes (3-step)	Descriptive	Descriptive
Inter-rater reliability	Excellent (kappa > 0.9)	Good (kappa ~0.8)	Variable
PADIS guideline endorsed	Yes	Yes	No
Paired delirium tool	CAM-ICU	CAM-ICU (adaptable)	None standard

The RASS and SAS are both recommended by the 2018 PADIS guidelines. The choice between them often depends on institutional familiarity and existing protocols. The RASS has a slight advantage in the number of sedation levels (five versus three), which may provide finer titration granularity. Its standardized three-step assessment procedure also reduces subjectivity. The Ramsay scale, though historically significant, is no longer recommended as a first-line tool due to limited agitation characterization and lower inter-rater reliability.

Emerging Trends and Future Directions

Several developments are expanding the way sedation depth is monitored in the ICU. Processed electroencephalography (pEEG) devices such as the bispectral index (BIS) monitor and the SedLine monitor provide continuous, objective measurements of brain electrical activity as a surrogate for sedation depth. While these tools may complement the RASS, particularly in paralyzed patients, current evidence does not support replacing behavioral scales with pEEG in general ICU populations. The PADIS guidelines suggest pEEG as an adjunct rather than a substitute for clinical assessment.

Artificial intelligence and machine learning approaches are also being explored to predict sedation needs based on continuous physiological data streams (heart rate variability, respiratory patterns, accelerometry). These models could potentially anticipate agitation episodes before they occur, allowing preemptive interventions. However, such approaches remain investigational and have not yet been validated for clinical decision-making.

Another area of growth is the integration of RASS-based sedation management into comprehensive digital clinical decision support systems that simultaneously address pain, delirium, early mobility, and ventilator liberation. By embedding the RASS into a holistic, automated workflow, these systems aim to improve adherence to guideline-based care bundles and reduce cognitive burden on clinicians.

Clinical Interpretation Framework

Interpreting a RASS score requires contextualizing it against the prescribed target and the patient's clinical trajectory. Key clinical considerations at each zone of the scale include the following:

RASS +3 to +4: Severe Agitation

This level represents a clinical emergency. The patient may be at immediate risk for self-harm, staff injury, or hemodynamic compromise. The priority is ensuring safety while rapidly identifying and treating reversible causes: pain, hypoxia, hypoglycemia, full bladder, drug withdrawal, or acute delirium. Pharmacological intervention with bolus sedatives, antipsychotics, or both is often required. Physical restraints may be applied per institutional policy when pharmacological measures are insufficient, but should be time-limited and reassessed frequently.

RASS +1 to +2: Mild to Moderate Agitation

These patients are uncomfortable but not dangerous. An analgesia-first approach is recommended: assess pain using a validated tool, treat if present, and then reassess RASS. Non-pharmacological strategies (reorientation, noise reduction, sleep hygiene, family presence, music therapy) should be trialed concurrently. If pharmacological sedation is needed, short-acting agents at the lowest effective dose are preferred.

RASS 0: Alert and Calm

This is the ideal target for most ICU patients. It indicates that the patient is awake, able to participate in care, and not in distress. It allows for meaningful neurological assessment, communication with the care team, and participation in early mobility activities. Maintaining RASS 0 should be the default unless a specific clinical indication requires deeper sedation.

RASS -1 to -2: Light Sedation

This range falls within the guideline-recommended target (RASS 0 to -2). Patients at this level are easily arousable and can participate in spontaneous breathing trials and early mobility. This zone offers an optimal balance between patient comfort and the avoidance of deep-sedation-related complications. Daily sedation interruption trials are appropriate at this level.

RASS -3: Moderate Sedation

At this level, the patient responds to voice with movement but not eye contact. Unless a specific indication for moderate-to-deep sedation exists, clinicians should consider whether the sedation depth is clinically warranted and attempt to lighten toward the -1 to 0 range.

RASS -4 to -5: Deep Sedation to Unarousable

Deep sedation should be reserved for patients with a clear clinical indication. When deep sedation is not intended, a RASS of -4 or -5 should trigger a reassessment of the sedation regimen, including a review of concurrent medications that may contribute to central nervous system depression (opioids, benzodiazepines, antiepileptics). Unexplained deep sedation may also indicate a new neurological event and should prompt a focused examination.