RASS

Richmond Agitation-Sedation Scale

RASS +4: Combative

Overtly combative, violent, immediate danger to staff

RASS +3: Very agitated

Pulls or removes tube(s) or catheter(s); aggressive

RASS +2: Agitated

Frequent nonpurposeful movement, fights ventilator

RASS +1: Restless

Anxious but movements not aggressive or vigorous

RASS 0: Alert and calm

RASS -1: Drowsy

Not fully alert, but has sustained awakening (eye opening/eye contact) to voice (>10 seconds)

RASS -2: Light sedation

Briefly awakens with eye contact to voice (<10 seconds)

RASS -3: Moderate sedation

Movement or eye opening to voice (but no eye contact)

RASS -4: Deep sedation

No response to voice, but movement or eye opening to physical stimulation

RASS -5: Unarousable

No response to voice or physical stimulation

Reference

Ely EW, Truman B, Shintani A, Thomason JWW, Wheeler AP, Gordon S, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003 Jun. 11;289(22):2983-2991.