Ramsay Scale: Sedation, Objectives, Pain Management, Scoring and Conclusion Systems

Establishing different levels of sedation is very important. Insufficient sedation can cause intense pain in the patient.

In the same way, an excess of sedation can put your health at risk.

The Ramsay scale was developed by the American physician Michael Ramsay. Currently, it is the most popular in the world to measure sedation.

Virtually all patients admitted to the intensive care unit (ICU) receive sedation therapy. Accurate control of the depth of sedation is often not well managed.

Frequently, patients are overestimated or underestimated with increased morbidity, mortality, and economic cost due to this lack of control.

More than 25 years ago, an attempt was made to take control of the level of sedation to the same level of intense management as the control of hemodynamics, fluid and electrolyte balances, and oxygen and metabolic parameters.

This concept has taken a long time to reach the path of critical attention of most ICUs.


However, economic problems and advances in pharmacology have led to a critical reassessment of sedation techniques. A patient’s goal is to maintain ventilator synchrony and be strongly sedated or unconscious.

Now it is changing to the objective, where possible, of a calm, cooperative, comfortable and communicative patient who can interact with family members and medical personnel.

This change in practice pattern has resulted in shorter periods with mechanical ventilation support, leading to a more temporary stay in the intensive care unit.

Objectives of sedation

The effective management of pain, anxiety, and sleep (hypnosis) are the main objectives of a sedation therapy regimen. The ICU setting often lends itself to an unpleasant experience for the critical patient.

The patient is exposed to numerous frightening and frightening procedures that are a necessary part of the care process.

Sedation therapy is administered to make this clinical field a more humane place to be treated.

Careful and precise control of sedation therapy can lead to better patient control that requires mechanical ventilation support and reduce the use of neuromuscular blocking agents.

The desired result of a sedation regimen is to allow the patient to tolerate the physical environment and the unpleasant procedures and therapies necessary in the ICU.

Post-traumatic stress disorder does not occur after discharge from the unit to facilitate nursing care and management and reduce anxiety and stress.

Patient safety is paramount, and it is essential to avoid self-extubation and accidental removal of catheters and other life-dependent equipment.

Amnesia is probably another practical goal of sedation therapy so that the patient does not remember unpleasant events or their environment.

However, it has been suggested that patients who recover from intensive care therapy may have an unrealistic perspective of their recovery if they do not remember the severity of their illness.

Pain management

Effective pain management is essential in the proper administration of sedation and improves patient satisfaction, faster recovery, and reduced complications.

This should be the priority when evaluating a patient’s sedation requirements. Appropriate analgesia may reduce the need for other sedative therapy.

Almost all patients in the ICU experience pain, either due to procedures performed on them, the disease process, catheters or tubes inserted into them, or because they are immobile and can not change position.

If the patient is paralyzed or clouded, he will have lost the ability to communicate the severe discomfort he is to the care team.

The sequelae of severe untreated pain can have long-lasting psychological effects on the patient and adverse hemodynamic changes.

Tachycardia and hypertension, together with an increase in systemic vascular resistance, will cause an increase in myocardial oxygen consumption and demand, which can cause myocardial ischemia.

Sedation scoring systems

A sedation scoring system should be an integral component of any sedation protocol.

The four most validated scoring systems include the Ramsay sedation scale, the sedation agitation scale, the motor activity assessment scale, and for the pediatric population; the comfort scale.

The Ramsay Sedation Scale

The Ramsay Sedation Scale (RSS, Table) was the first scale defined and designed as a usability test.

ACCORDING TO HOW VIABLE THE PATIENT IS, the RSS scores sedation at six different levels. It is an intuitively obvious scale and, therefore, lends itself to universal use in the ICU and where sedative or narcotic drugs are administered.

It can be added to the pain score and considered the sixth vital sign.

  1. The patient is anxious and agitated, restless, or both.
  2. The patient is cooperative, oriented, and calm.
  3. The patient responds only to the commands.
  4. The patient exhibits an energetic response to mild glabellar touch or solid auditory stimulation.
  5. The patient exhibits a slow reaction to gentle glabellar touch or reliable auditory stimulation.
  6. The patient does not show an answer.

The RSS defines the conscious state from a level.

If the patient is asleep, a reuse test should be performed. If the patient responds quickly to a voice command, this is an RSS 3. If the response is slow, the patient is assigned a level 4.

If the patient does not respond, a more potent stimulus is applied. It activates a more substantial auditory stimulation or a glabellar griffin (between the eyebrows).

An enthusiastic response to this viability test places the patient in an RSS 4. A slow response categorizes the patient in an RSS 5. No response at all places the patient at a level 6.

The stimulus of reusability was explicitly designed not to be a painful test and not scare the patient. It was planned that a sleeping patient would not wake up in a fully awake state so that the sleep pattern would not be disturbed.

A disadvantage of RSS is that it depends on the ability of the patient to respond. Therefore, the patient who has received neuromuscular blockers can not be evaluated in this way.

Also, in a level 1 score, there is no more definition of the degree of agitation, and there are times when this may be important to record.

The Sedation-Agitation Scale considers this. At the deepest end of the scale, an RSS 6, there is no more information about whether the patient is in a light plane of general anesthesia or deep coma.

This evaluation can be made by monitoring the signal of the compressed spectral set of an electroencephalogram. A bispectral index score of 61.7 correlates well with an RSS of 6.


Despite the availability of sedation scales in the last 25 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, less than half of patients are at the prescribed level for more than 50% of the time.

Therefore, there is still an opportunity to educate on the importance of evaluation dynamics, reassessment, and adjustment in the sedative administration rate. This dynamic is essential to avoid the complications associated with excessive or insufficient sedation.