What is the difference between the pediatric agitation sedation scale (PASS) and the Richmond agitation sedation scale (RASS) in assessing and managing agitation in pediatric patients?

Pediatric Agitation Sedation Scale vs Richmond Agitation Sedation Scale

The Richmond Agitation-Sedation Scale (RASS) is a validated, reliable tool for assessing both agitation and sedation in pediatric intensive care patients and should be used over other scales when a single instrument is needed to assess the full spectrum from deep sedation to combative agitation. 1, 2

Key Differences Between RASS and Pediatric-Specific Scales

Richmond Agitation-Sedation Scale (RASS)

• RASS is a 10-point scale ranging from +4 (combative) to -5 (unarousable) that captures both agitation and sedation on a single continuum 1, 2, 3
• Originally developed for adults but has been validated in critically ill children ages 2 months to 21 years with excellent inter-rater reliability (weighted kappa 0.946) 1
• Shows excellent correlation with the COMFORT Behavior Scale (rho = 0.935) and numeric rating scales (rho = 0.958) in pediatric populations 1
• Works equally well in mechanically ventilated and spontaneously breathing children 2
• Demonstrates excellent inter-rater agreement between nurses and physicians (weighted kappa 0.825) 2

Pediatric Anesthesia Emergence Delirium (PAED) Scale

• The PAED Scale is specifically designed to identify emergence delirium in the postanesthesia care unit, not for ongoing sedation assessment 4
• More sensitive than RASS for detecting emergence delirium (11.5% vs 7.5% detection rate) 4
• Should be used specifically in the post-anesthesia recovery setting rather than for continuous PICU sedation monitoring 4

State Behavioral Scale (SBS)

• Designed specifically for infants and young children (6 weeks to 6 years) on mechanical ventilation 5
• Uses eight behavioral dimensions including respiratory drive, response to ventilation, coughing, response to stimulation, attentiveness, tolerance to care, consolability, and movement 5
• More complex to administer than RASS, requiring observation and incremental stimulation over several minutes 5
• Has not been as extensively validated across diverse pediatric populations as RASS 5

Clinical Application Guidelines

When to Use RASS

• For routine sedation monitoring in pediatric intensive care patients of all ages 1, 2
• When a single tool is needed to assess both oversedation and agitation 1
• In both mechanically ventilated and spontaneously breathing patients 2
• The COMFORT Behavior Scale should be used alongside RASS as recommended by ESPNIC guidelines for comprehensive assessment 6

When to Use PAED Scale

• Specifically in the postanesthesia care unit to identify emergence delirium 4
• When LOC-RASS underdetects agitation in the immediate postoperative period 4

When to Use State Behavioral Scale

• In very young children (under 6 years) on mechanical ventilation when detailed behavioral assessment is needed 5
• When institutional preference exists for more granular behavioral dimension assessment 5

Monitoring Frequency and Documentation

Sedation level must be assessed and documented every 4-8 hours or as indicated by clinical condition, alongside vital signs 6

• More frequent assessment (every 5 minutes) is required during moderate or deep sedation procedures 6
• Continuous observation by a competent individual not performing the procedure is mandatory during sedation 6
• Vital signs including heart rate, respiratory rate, blood pressure, oxygen saturation, and end-tidal CO2 must be documented at least every 5 minutes during deep sedation 6

Critical Pitfalls to Avoid

• Do not assume the RASS cannot be used in pediatrics—it has been extensively validated in children as young as 2 months 1, 2
• Avoid using the LOC-RASS alone in the postanesthesia setting, as it significantly underdetects emergence delirium compared to the PAED Scale 4
• Remember that children commonly progress from intended sedation levels to deeper levels; practitioners must be skilled to rescue from one level deeper than intended 6
• Do not rely solely on clinical judgment without structured assessment tools—validated scales improve sedation quality and safety 6
• Oversedation increases risk of prolonged mechanical ventilation and healthcare costs, while undersedation leads to self-extubation and line displacement 6

Practical Implementation

RASS is described by nurses as logical, easy to administer, and readily recalled, making it ideal for routine bedside use 3

• The scale requires minimal training with excellent inter-rater reliability maintained after implementation 3
• RASS can distinguish between deep sedation, moderate-light sedation, and agitation categories effectively 1
• The tool responds appropriately to changes in sedative dosing, confirming its clinical utility 1