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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.