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Ramsay sedation scale

Score 1 2 3 4 " Response Anxious or restless or both Cooperative, orientated and tranquil Responding to commands Brisk response to stimulus !luggish response to stimulus #o response to stimulus

Motor activity assessment scale


Score Level of sedation Response to stimulation Response to command Examples of type of complex motor activity

"

$angerousl% agitated and uncooperative&

(atient pulling at tubes or catheters or #o external stimulus $oes not thrashing required to elicit calm do'n )rom side to movement& 'hen asked& side or striking at sta)) or tr%ing to climb out o) bed& $oes not consistentl% obe% (atient commands #o external stimulus attempts to *eg 'ill lie required to elicit sit up and do'n 'hen movement& moves limbs asked but out o) bed& soon reverts to attempts to sit up+ #o external stimulus ,be%s (atient is required to elicit commands& picking at

Agitated&

Restless but cooperative

movement&

sheets or tubes or uncovering sel)&

Calm and cooperative

(atient #o external stimulus ad-usts ,be%s required to elicit sheets or commands& movement& clothes purpose)ull%& ,pens e%es or raises e%ebro's or turns head to'ard stimulus or moves limbs 'hen touched or name is loudl% spoken& ,pens e%es or raises e%ebro's or turns head to'ard stimulus or moves limbs in response to noxious stimulus *tracheal suctioning or secs o) vigorous orbital, sternal or nailbed pressure+ $oes not move 'ith noxious stimulus

Responsive to touch or name

Responsive onl% to noxious stimuli

/nresponsive

Sedation-agitation scale

Score 0 "

Level of sedationResponse agitation $angerous agitation 1er% agitated Agitated Calm and cooperative !edated 1er% sedated /narousable (ulling at endotracheal tube, thrashing, climbing over bed rails $oes not calm, requires restraints, bites endotracheal tube Attempts to sit up but calms to verbal instructions ,be%s commands $i))icult to rouse, obe%ss simple commands Rouses to stimuli& $oes not obe% commands 2inimal or no response to noxious stimuli

4 3 2 1

3urther reading
4iu 44, 5ropper 2A& (ostoperative analgesia and sedation in the adult intensive care unit& A guide to drug selection& $rugs, 2..36 "3*7+80 9"0

How to use the Ramsay Score to assess the level of ICU Sedation Michael A. E. Ramsay M.D.
Introduction Virtually every patient admitted into the intensive care unit (ICU) is administered sedation therapy. The precise control of the depth of sedation is often not well managed. Patients are frequently over or under sedated with! as a result of this lac" of control! an accompanying increase in mor#idity! mortality and economic cost. $ver %& years ago! an attempt was initiated to #ring the control of sedation level up to the same level of intense management as the control of hemodynamics! fluid and electrolyte #alances! o'ygen and meta#olic parameters ()*. This concept has ta"en a long time to reach the critical care pathway of the ma+ority of ICUs. ,owever! economic issues and advances in pharmacology! have lead to a critical re evaluation of sedation techniques! so that the goal of a heavily sedated or comatose patient for the maintenance of ventilator synchrony! is now changing to the goal! where possi#le! of a calm! co operative! comforta#le and communicative patient! who can interact with family mem#ers and medical staff. This change in practice pattern has resulted in shorter periods of time on mechanical ventilation support! leading to a shorter stay in the intensive care unit (%!-*. Sedation goals The effective management of pain! an'iety and sleep (hypnosis) are the ma+or aims of a sedation therapy regimen. The ICU environment frequently lends itself to #eing an unpleasant e'perience for the critically ill patient. The patient is e'posed to numerous ominous and frightening procedures that are a necessary part of the care process. In an effort to ma"e this clinical arena a more humane place to #e treated! sedation therapy is administered. The careful and precise control of sedation therapy may lead to #etter control of the patient requiring mechanical ventilation support! and reduce the requirement for the use of neuromuscular #loc"ing agents. The desired result of a sedation regimen is to allow the patient to tolerate the physical environment! and the unpleasant procedures and therapies that are necessary in the ICU. to facilitate nursing care and management! and reduce #oth an'iety and stress! so that post traumatic stress disorder does not occur after discharge from the unit. Patient safety is paramount! and the avoidance of self

e'tu#ation and inadvertent removal of catheters and other life dependency equipment is essential. /mnesia is pro#a#ly another useful goal of sedation therapy! so that the patient has no recall of unpleasant events or surroundings. It has! however! #een suggested that patients recovering from intensive care therapy! may have an unrealistic outloo" on their recovery! if they have no recall on the severity of their illness (0*. The #lunting of autonomic responses! reduced o'ygen consumption and ventilator synchrony are other important goals of sedation therapy. The maintenance of a normal sleep pattern can help maintain psychological well #eing! as well as preventing e'haustion and the loss of a desire to survive. Patient agitation is another common pro#lem in the critical care unit! it may result from a specific cause such as hypo'ia! under ventilation! meta#olic derangement and other correcta#le entities that should #e addressed first! #ut it may #e the result of sleep deprivation! or pharmacological interactions! and require sedation to control (& 1*. Pain management The effective management of pain is essential in the proper management of sedation! and results in improved patient satisfaction! a faster recovery with reduced complications ()2*. This has to #e the priority when assessing a patient3s sedation requirements. /dequate analgesia may reduce the necessity for other sedative therapy. 4early all patients in the ICU e'perience pain! whether it is the result of procedures performed on them! the disease process! catheters or tu#es inserted into them! or #ecause they are immo#ile and cannot shift position. If the patient is paraly5ed or o#tunded! they will have lost the a#ility to communicate the severe discomfort that they may #e in! to the care team. The sequelae of severe untreated pain can #e long lasting psychological effects on the patient! together with adverse haemodynamic changes. Tachycardia and hypertension! together with an increase in systemic vascular resistance! will cause an increase in myocardial o'ygen consumption and demand! that may result in myocardial ischemia ()2*. There may also #e a deleterious effect on the immune system in an all ready compromi5ed patient who is trying to com#at a serious illness! #ut foremost it is inhumane not to adequately treat pain. The precise control of pain can reduce the need for deep sedation and reduce the necessity for muscle rela'ants. The mainstay of analgesic therapy is still the opiates. 6orphine or fentanyl are two of the narcotics most frequently administered in the ICU. They are effective pain relievers! #ut come with significant side effects! that may have a deleterious effect on the patient ())*. The #alance #etween the adverse effects of the opioid analgesics! and the #eneficial effect of analgesia! is a limiting factor in their use and the appropriate pain therapy delivered to these critically ill patients. These

adverse effects include respiratory depression! deep sedation! narcotic #owel syndrome! pruritus! nausea! vomiting and a decreased a#ility to communicate. 4early all the narcotics have active meta#olites that will cause a prolongation of their effects when continually administered to patients with multi organ system failure. This is the common profile for the intensive care patient. therefore there may #e an insidious #uild up in the narcotic actions of these agents. 7emifentanil! a relatively new! mu receptor specific opiate that is rapidly meta#oli5ed #y non specific esterases into meta#olites with very wea" narcotic activity! may have a future role to play in the close control of pain in the critically ill patient ()%*. Over sedation The results of over sedation in the mechanically ventilated patient are an increased time #eing ventilated! an increased time in the intensive care unit! and an increased cost of care. The common effect of an increasing dose of most sedative agents is respiratory depression. This may facilitate ventilator synchrony! #ut will prolong the weaning process. In the e'tu#ated patient it may #e associated with severe hypercar#ia! hypo'ia and respiratory arrest. There is no sensitive monitor of respiratory depression in the e'tu#ated patient! who is receiving supplementary o'ygen. Under these circumstances! the only parameters that correlate well with respiratory depression are respiratory pattern and level of consciousness. 7espiratory rate and end tidal car#on dio'ide measured via a nasal cannula! are not relia#le monitors of depressed respiration ()-*. The pulse o'imeter is a 8/T9 detector of respiratory depression! when there is an increased concentration of inspired o'ygen ()0*. Under sedation The untoward effects of under sedation include an increased production of endogenous catecholamines! that results in an increase in #lood pressure! heart rate and myocardial o'ygen consumption. The patient may #e at ris" for self in+ury from the accidental removal of the endotracheal tu#e or vital catheters. The mental sequelae from #eing awa"e while painful! and terrifying procedures are performed on the patient can #e the development of a post traumatic stress disorder! that may require prolonged therapy after discharge ()&*. The patients: who are unresponsive #ecause of the administration of neuromuscular #loc"ing drugs are most at ris" ();*. <leep deprivation is very common! and can result in the development of the typical ICU psychosis ()=*.

Controlled Sedation To prevent the adverse complications of poorly controlled sedation! sedation therapy should #e administered in a careful and precise manner. The depth of sedation should #e clearly defined and the infusion of sedative drug precisely targeted to this clinical endpoint. If the patient is sedated to an unrousa#le depth! then unless clinically contraindicated! they should #e #rought to a level where a neurological assessment can #e made every %0 hours ()>*. In his manner a cere#ral insult will not go undetected. ?y defining the sedation level and carefully controlling the sedation infusion to meet this endpoint! the dangers of over or under sedation are minimi5ed. It will also provide for continuity of care! as all care givers understand the required depth of sedation. To #e a#le to reach this goal the routine use of sedation scales is essential. The scoring system selected for use must #e easily understood! used routinely and #e part of the regular assessment of the ICU patient In fact sedation scoring systems should #e in regular use where ever potent respiratory depressant drugs are #eing used. Sedation Scoring Systems. / sedation scoring system should #e an integral component of any sedation protocol. The four most validated scoring systems include@ The 7amsay <edation <cale. The <edation /gitation <cale. The 6otor /ctivity /ssessment <cale and for the pediatric population@ The Comfort <cale ()1*. he Ramsay Sedation Scale The 7amsay <edation <cale (7<<! Ta#le)! was the first scale to #e defined and was designed as a test of rousa#ility. The 7<< scores sedation at si' different levels! according to how rousa#le the patient is. It is an intuitively o#vious scale and therefore lends itself to universal use! not only in the ICU! #ut wherever sedative drugs or narcotics are given. It can #e added to the pain score and #e considered the si'th vital sign. Ramsay Sedation Scale ) Patient is an'ious and agitated or restless! or #oth % Patient is co operative! oriented! and tranquil - Patient responds to commands only 0 Patient e'hi#its #ris" response to light gla#ellar tap or loud auditory stimulus & Patient e'hi#its a sluggish response to light gla#ellar tap or loud auditory stimulus ; Patient e'hi#its no response

The 7<< defines the conscious state from a level )@ the patient is an'ious! agitated or restless! through the continuum of sedation to a level ;@ the patient is completely unresponsive. Therefore when an assessment is to #e made! the first decision to #e made is to note if the patient is awa"e. If the patient is awa"e@ are they an'ious! agitated or restless (7<< )) or are they calm! co operative and communicative (7<< %)A If the patient is asleep then a test of reusa#ility needs to #e made. If the patient responds quic"ly to a voice command! this is a 7<< -. If the response is slow then the patient is assigned a level 0. If the patient does not respond a stronger stimulus is applied. / louder auditory stimulus or a gla#ellar (#etween the eye#rows) tap is enacted. / #ris" response to this test of rousa#ilty places the patient at a 7<< 0. / slow or sluggish response categori5es the patient to a 7<< &. 4o response at all places the patient at a level ;. The rousa#ility stimulus was specifically designed not to #e a painful test and not to startle the patient. In fact it was planned that a sleeping patient would not #e roused to a fully awa"ened state! so that the sleep pattern would not #e distur#ed. / disadvantage of the 7<< is that it relies on the a#ility of the patient to respond! therefore the patient who has received neuromuscular #loc"ing drugs cannot #e assessed in this manner. /lso at a level ) score! there is no further definition of the degree of agitation! and there are occasions when this may #e important to record. The <edation /gitation <cale does ta"e this into consideration (%2*. /t the deep end of the scale! a 7<< ;! there is no further information as to whether the patient is in a light plane of general anesthesia or deep coma. This assessment can #e made from monitoring the compressed spectral array signal from an electroencephalogram! / #ispectral inde' score of ;).= correlates well with a 7<< of ; (%)*. Conclusion Bespite the ready availa#ility of sedation scales over the last %& years! a review of ICU practice reveals that many units still do not closely control the level of sedation in their critically ill patients. In those units where sedation scoring systems are used fewer than half the patients are at the prescri#ed level for more than &2C of the time. Therefore there is still an opportunity to educate the importance of the dynamics of assessment! re assessment and ad+ustment in the rate of delivery of sedative. This dynamic is essential to avoid the complications associated with over and under sedation.

References
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