From the Guidelines
The Sedation Agitation Scale (SAS) is a crucial tool for assessing and monitoring the level of sedation and agitation in critically ill patients, with a target score of 3-4 for most patients, as recommended by the clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit 1. The SAS consists of seven levels ranging from 1 to 7, where 1 represents unarousable sedation, 4 indicates a calm and cooperative state, and 7 represents dangerous agitation. Key points to consider when using the SAS include:
- Assessing agitation and sedation levels regularly, every 4-8 hours or whenever there's a change in the patient's condition or after sedative medication adjustments
- Using the SAS to guide appropriate dosing of sedative medications, such as propofol, midazolam, or dexmedetomidine
- Avoiding under-sedation, which can lead to self-extubation or removal of medical devices, and over-sedation, which can prolong mechanical ventilation and ICU stay
- Regular SAS assessments enable a goal-directed approach to sedation management, improving patient outcomes and reducing complications associated with critical illness, as supported by the guidelines 1. The SAS is a validated clinical tool, and its use is recommended in conjunction with other sedation assessment tools, such as the Richmond Agitation-Sedation Scale (RASS), to ensure accurate and reliable assessments of sedation and agitation levels in critically ill patients. Some key considerations for sedation management include:
- Targeted sedation or DSI (Goal: patient purposely follows commands without agitation): RASS = -2 - 0, SAS = 3 - 4
- If under sedated (RASS >0, SAS >4) assess/treat pain (non-benzodiazepines preferred, unless ETOH or treat w/ sedatives prn)
- If over sedated (RASS <-2, SAS <3) hold sedatives until at target; then restart at 50% of previous dose, as outlined in the guidelines 1.
From the Research
Overview of Sedation Agitation Scale
- The Sedation Agitation Scale is a tool used to assess the level of sedation and agitation in patients, particularly in intensive care unit (ICU) settings 2, 3.
- The scale typically ranges from a score of 1 (unarousable) to 7 (dangerous agitation), with higher scores indicating increased agitation and lower scores indicating deeper sedation 3, 4.
Types of Sedation Agitation Scales
- The Richmond Agitation-Sedation Scale (RASS) is a 10-level scale that assesses sedation and agitation in adult ICU patients, ranging from +4 (combative) to -5 (unarousable) 2.
- The Sedation-Agitation Scale (SAS) is a 7-level scale that assesses sedation and agitation in adult ICU patients, ranging from 1 (unarousable) to 7 (dangerous agitation) 3.
- The RASS has been modified for use in palliative care settings (RASS-PAL) and has shown preliminary validity evidence for assessing sedation and agitation levels in this population 5.
Validity and Reliability
- The RASS has been shown to have high inter-rater reliability and validity in adult ICU patients, with excellent correlation with other sedation scales such as the Ramsay sedation scale and the Sedation Agitation Scale 2, 3.
- The SAS has also been shown to have high inter-rater reliability and validity in adult ICU patients, with high correlation with other sedation scales such as the Ramsay scale and the Harris scale 3.
- The RASS has been validated for use in pediatric intensive care patients, with excellent inter-rater reliability and construct validity 6.
Clinical Applications
- The Sedation Agitation Scale can be used to guide sedation therapy and monitor patients' responses to sedative medications 4.
- The scale can also be used to assess the effectiveness of sedation and agitation management strategies in ICU patients 2, 3.
- The RASS-PAL has been shown to be useful in assessing sedation and agitation levels in palliative care patients, particularly in the management of palliative sedation 5.