RASS stands for 'Richmond Agitation and Sedation Scale'. It is used in ICU to assess levels of consciousness for patients on sedative medications (so, usually intubated and ventilated too, to protect their airway), where a GCS (Glasgow Coma Scale) score might not accurately reflect the patients condition - in an intubated, sedated patient, the maximum score is 11/15 due to lack of verbal response and this score will be even lower if they are on sedation to facilitate ventilator synchrony, for example. RASS scores, however, are closely associated with GCS and CAM-ICU assessments- pain, agitation and delirium are all interlinked.
A RASS score can be used to help titrate sedative medications to achieve a target RASS and avoid over/under sedation- sedation is a bit of a Goldilocks principle- not too much, not too little, but juuuust right. Actions such as a daily sedation hold can be used to assess levels of sedation and be used to titrate sedative and analgesic infusions.
More often than not, you will be aiming for a RASS of 0, where the patient is alert and calm. However, there may be exceptions to this rule- for example a freshly post op max fax patient who needs their neck to be kept straight with minimal movement for the first 24 hours post surgery. Here, the surgeons may request a RASS of -2/-3 for the first 24 hours post op.
Over sedation increases time being mechanically ventilated (therefore increased VAP) and therefore is associated with increased ICU LOS and potentially increased incidence of delirium and mortality.
Under sedation can lead to pain and anxiety, causing increased intracranial pressure and cardiovascular instability. There is also the risk of self extubation and accidental line removal, ventilator asynchrony and increased mortality.
RASS Scoring system-
Step 1- observe the patient.
1a) patient is alert and calm? (0)
1b) patient is restless or agitated? (+1 - +4)
Step 2- attempt to rouse the patient verbally- say patients name and ask them to open their eyes and look at you.
2a) patient looks at you with eye contact for more than 10 seconds (-1)
2b) patient looks at you with eye contact but sustained for less than 10 seconds (-2)
2c) patient moves in response to voice but makes no eye contact (-3)
2d) patient does not respond to voice
Step 3- attempt to rouse the patient physically- apply stimulus by shaking patients shoulder or perform trapezius squeeze.
3a) patient moves in response to physical stimuli (-4)
3b) patient does not respond to physical stimuli (-5)
NOTE- RASS scoring does not apply if the patient is asleep (recorded as S) or paralysed on muscle relaxants (recorded as P)
Once RASS has been scored, sedation can be increased or decreased dependent on patient targets.
It is also important to carry out further assessments such as the CAM ICU dependent on the RASS score. CAM-ICU is not applicable for RASS -4 and -5. At -3, it is clinician judgement whether patient is conscious enough to participate in the assessment. Patients at RASS -2 to +4 should be assessed for delirium. A strength of the RASS scoring system is that it combines elements of a CAM ICU assessment by including presence of inattention, as measured by presence of lack of eye contact, so can be used as a rough predictor of delirium.
Other strengths of the RASS include that it is a validated tool for use in ICU, shows good inter-rater reliability between nurses and other medical professionals, and is quick and easy to complete. Plus, the obvious advantage over GCS of not relying on a verbal response so that scoring is accurate for intubated patients.
Thank you for reading through this quick 'how to' on RASS scores! Hopefully it was helpful. Posts related to this one include CAM-ICU and Sedation Holds, so feel free to check those out too. Any questions/comments/suggestions, please don't hesitate to reach out via the blog or through twitter/instagram (@christienursing)
References-
MDCalc (2021) 'Richmond Agitation and Sedation Scale (RASS)' https://www.mdcalc.com/richmond-agitation-sedation-scale-rass#use-cases
Society of Critical Care Medicine (2018) 'Agitation/Sedation: 2018 SCCM clinical practice guidelines for the prevention and management of Pain, Agitation/sedation, Delirium, Immobility, and Sleep disruption in adult patients in the ICU' https://www.sccm.org/getattachment/6f733f9a-5b82-43b2-b262-91d788bee3e3/PADIS-Guidelines-Teaching-Slides-Sedation
Ely, W., Truman, B., Shintani, A., Thomason, J., Wheeler, A., Gordon, S., Francis, J., Speroff, T., Gautam, S., Margolin, R., Sessler, C., Dittus, R., Bernard, G. (2003) 'Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS)' in Journal of the American Medical Association. 289(22), pp. 2983-2991. https://jamanetwork.com/journals/jama/fullarticle/196696
Wes Ely is kind of the ICU king of sedation- he's responsible for a lot of work about sedation scoring and sedation holds.
Sessler, C., Gosnell, M., Grap, M., Brophy, G., O'Neal, P., Keane, K., Tesoro, E., Elswick, R. (2002) 'The Richmond Agitation Sedation Scale validity and reliability in adult intensive care patients' in American Journal of Respiratory and Critical Care Medicine. 166(10), pp. 1338-1344. https://www.atsjournals.org/doi/pdf/10.1164/rccm.210713
Oxford University Hospitals (2008) 'Richmond Agitation Sedation Scale (RASS)'
Baid, H., Creed, F., Hargreaves, J. (2016) Oxford Handbook of Critical Care Nursing, 2nd edn. Oxford: Oxford University Press
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