Sedation Scales in the ICU

Abstract

“Today we will be mixing… the Draught of Peace, a potion to calm anxiety and soothe agitation. Be warned: if you are too heavy-handed with the ingredients you will put the drinker into a heavy and sometimes irreversible sleep, so you will need to pay attention to what you are doing,”1Rowling JK Harry Potter and the order of the phoenix. Arthur A. Levine Books, New York, NY2003: 232Google Scholar admonished potions teacher Severus Snape as he addressed Harry Potter and his classmates at Hogwarts School of Witchcraft and Wizardry.Many of the millions of ICU patients undergoing mechanical ventilation worldwide receive sedative and analgesic medications during their hospitalization.2Hansen-Flaschen JH Brazinsky S Basile C et al.Use of sedating drugs and neuromuscular blocking agents in patients requiring mechanical ventilation for respiratory failure: a national survey.JAMA. 1991; 266: 2870-2875Crossref PubMed Scopus (292) Google Scholar3Christensen BV Thunedborg LP Use of sedatives, analgesics and neuromuscular blocking agents in Danish ICUs 1996/97: A national survey.Intensive Care Med. 1999; 25: 186-191Crossref PubMed Scopus (75) Google Scholar4Park G Coursin D Ely EW et al.Balancing sedation and analgesia in the critically ill.Crit Care Clin. 2001; 17: 1015-1027Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar The principle goals of these interventions are to provide comfort and minimize pain, suffering, anxiety, and other forms of distress, some of which are the result of ICU interventions.5Sessler CN Comfort and distress in the ICU: scope of the problem.Semin Respir Crit Care Med. 2001; 22: 111-113Crossref PubMed Scopus (12) Google Scholar Clinicians strive to optimize management by recognizing and treating underlying conditions, using nonpharmacologic techniques, selecting the best medication(s) for that individual patient, and administering the lowest effective dose for the shortest possible time.6Jacobi J Fraser GL Coursin DB et al.Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.Crit Care Med. 2002; 30: 119-141Crossref PubMed Scopus (1510) Google Scholar7Sessler CN Grap MJ Brophy GM Multidisciplinary management of sedation and analgesia in critical care.Semin Respir Crit Care Med. 2001; 22: 211-225Crossref PubMed Scopus (80) Google Scholar8Kress JP Pohlman AS Hall JB Sedation and analgesia in the intensive care unit.Am J Respir Crit Care Med. 2002; 166: 1024-1028Crossref PubMed Scopus (98) Google Scholar Yet, the medications are imperfect, potentially causing unwanted effects, including idiosyncratic or dose-related side effects, as well as problems related to the immobility and loss of protective reflexes that accompanies deep sedation.6Jacobi J Fraser GL Coursin DB et al.Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.Crit Care Med. 2002; 30: 119-141Crossref PubMed Scopus (1510) Google Scholar7Sessler CN Grap MJ Brophy GM Multidisciplinary management of sedation and analgesia in critical care.Semin Respir Crit Care Med. 2001; 22: 211-225Crossref PubMed Scopus (80) Google Scholar8Kress JP Pohlman AS Hall JB Sedation and analgesia in the intensive care unit.Am J Respir Crit Care Med. 2002; 166: 1024-1028Crossref PubMed Scopus (98) Google Scholar Additionally, persistent or excessive drug-induced sedation, particularly accompanying the “cruise control” of continuous infusion, may prolong hospitalization and thus expose the patient to further risks such as added testing, tracheostomy, and ICU complications.9Kress JP Pohlman AS O’Connor MF et al.Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation.N Engl J Med. 2000; 342: 1471-1477Crossref PubMed Scopus (2235) Google Scholar10Brook AD Ahrens TS Schaiff R et al.Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation.Crit Care Med. 1999; 27: 2609-2615Crossref PubMed Scopus (806) Google Scholar11Schweickert WD Gehlbach BK Pohlman AS et al.Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients.Crit Care Med. 2004; 32: 1272-1276Crossref PubMed Scopus (317) Google Scholar12Sessler CN Wake up and breathe.Crit Care Med. 2004; 32: 1413-1414Crossref PubMed Scopus (10) Google Scholar13Kollef MH Levy NT Ahrens TS et al.The use of continuous IV sedation is associated with prolongation of mechanical ventilation.Chest. 1998; 114: 541-548Abstract Full Text Full Text PDF PubMed Scopus (733) Google ScholarAdministration of the optimal dose of any medication requires knowledge of the desired and potentially unwanted drug effects, keen observation, and a process of repeated assessment and titration of dosage. Recognition that this is a dynamic process is important, since sedative needs differ from patient to patient, and may vary markedly over time for any given patient. To be considered effective, the drug(s) and dosage should meet the primary goal(s) for the individual patient, such as to control pain, to facilitate patient tolerance of mechanical ventilation, or to control agitated behavior. While it may be clear when the goal is not met (ie, the patient reports pain or is overtly agitated), clinicians have often relied on indirect, and nonspecific, signs of “distress” such as facial grimacing, or unexplained tachycardia, tachypnea, hypertension, diaphoresis, or tearing.6Jacobi J Fraser GL Coursin DB et al.Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.Crit Care Med. 2002; 30: 119-141Crossref PubMed Scopus (1510) Google Scholar17Riker RR Fraser GL Monitoring sedation, agitation, analgesia, neuromuscular blockade, and delirium in adult ICU patients.Semin Respir Crit Care Med. 2001; 22: 189-198Crossref PubMed Scopus (38) Google Scholar However, the patient who is no longer experiencing distress may, in fact, be receiving an excessive dose, with progressive accumulation of drug and/or active metabolites resulting in delayed recovery. A structured approach to sedation management that emphasizes close monitoring and goal-directed titration of medications can improve this process.6Jacobi J Fraser GL Coursin DB et al.Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.Crit Care Med. 2002; 30: 119-141Crossref PubMed Scopus (1510) Google Scholar7Sessler CN Grap MJ Brophy GM Multidisciplinary management of sedation and analgesia in critical care.Semin Respir Crit Care Med. 2001; 22: 211-225Crossref PubMed Scopus (80) Google Scholar In many hospitals, this quest is pursued by a multidisciplinary team that includes physicians, nurses, and pharmacists working in concert.7Sessler CN Grap MJ Brophy GM Multidisciplinary management of sedation and analgesia in critical care.Semin Respir Crit Care Med. 2001; 22: 211-225Crossref PubMed Scopus (80) Google Scholar A key component of this approach is the use of a sedation scale, a tool that can enhance accurate and consistent medication titration by clinicians, improve understanding and communication,6Jacobi J Fraser GL Coursin DB et al.Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.Crit Care Med. 2002; 30: 119-141Crossref PubMed Scopus (1510) Google Scholar7Sessler CN Grap MJ Brophy GM Multidisciplinary management of sedation and analgesia in critical care.Semin Respir Crit Care Med. 2001; 22: 211-225Crossref PubMed Scopus (80) Google Scholar15De Jonghe B Cook D Appere-De-Vecchi C et al.Using and understanding sedation scoring systems: a systematic review.Intensive Care Med. 2000; 26: 275-285Crossref PubMed Scopus (293) Google Scholar and reduce the incidence of excessive drug-induced stupor.16Costa J Cabre L Molina R et al.Cost of ICU sedation.Clin Intensive Care. 1994; 5: 17-21Google Scholar In this issue of CHEST (see page 1883), Dr. Weinert and Ms. McFarland report the development and validation of such a scale, the Minnesota Sedation Assessment Tool (MSAT).The development and validation of tools to describe and quantify patient behavior related to sedation and agitation in the ICU setting has grown remarkably in recent years.6Jacobi J Fraser GL Coursin DB et al.Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.Crit Care Med. 2002; 30: 119-141Crossref PubMed Scopus (1510) Google Scholar15De Jonghe B Cook D Appere-De-Vecchi C et al.Using and understanding sedation scoring systems: a systematic review.Intensive Care Med. 2000; 26: 275-285Crossref PubMed Scopus (293) Google Scholar17Riker RR Fraser GL Monitoring sedation, agitation, analgesia, neuromuscular blockade, and delirium in adult ICU patients.Semin Respir Crit Care Med. 2001; 22: 189-198Crossref PubMed Scopus (38) Google Scholar Although the Ramsay Sedation Scale was introduced 30 years ago,18Ramsay MA Savege TM Simpson BR et al.Controlled sedation with alphaxalone-alphadolone.BMJ. 1974; 2: 656-659Crossref PubMed Scopus (2212) Google Scholar several decades passed until interest in quantifying patient agitation as part of the behavioral assessment prompted development of the Sedation Agitation Scale (SAS),19Riker RR Fraser GL Cox PM Continuous infusion of haloperidol controls agitation in critically ill patients.Crit Care Med. 1994; 22: 433-440Crossref PubMed Scopus (234) Google Scholar20Riker RR Picard JT Fraser GL Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients.Crit Care Med. 1999; 27: 1325-1329Crossref PubMed Scopus (714) Google Scholar the Motor Activity Assessment Scale,21Devlin JW Boleski G Mlynarek M et al.Motor Activity Assessment Scale: a valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit.Crit Care Med. 1999; 27: 1271-1275Crossref PubMed Scopus (287) Google Scholar the Vancouver Interactive and Calmness Scale (VICS),22de Lemos J Tweeddale M Chittock D Measuring quality of sedation in adult mechanically ventilated critically ill patients: the Vancouver interaction and calmness scale.J Clin Epidemiol. 2000; 53: 908-919Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar and others. The most recently validated sedation scales, such as the Richmond Agitation Sedation Scale (RASS),23Sessler CN Gosnell MS Grap MJ et al.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Am J Respir Crit Care Med. 2002; 166: 1338-1344Crossref PubMed Scopus (2146) Google Scholar the awakeness domain of the Adaptation to the Intensive Care Environment (ATICE) instrument,24De Jonghe B Cook D Griffith L et al.Adaptation to the Intensive Care Environment (ATICE): development and validation of a new sedation assessment instrument.Crit Care Med. 2003; 31: 2344-2354Crossref PubMed Scopus (138) Google Scholar and the arousal domain of the MSAT, employ direct observation of simple patient responses (ie, eye opening, movement) to simple maneuvers such as to auditory and physical stimulation, and have multiple sedation levels that might be targeted for more effective medication titration.What are desirable features of a sedation scale? Common themes include rigorous multidisciplinary development; ease of administration, recall, and interpretation; well-defined discrete criteria for each level; sufficient sedation levels for effective drug titration; assessment of agitation; demonstration of interrater reliability for relevant patient populations; and evidence for validity.6Jacobi J Fraser GL Coursin DB et al.Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.Crit Care Med. 2002; 30: 119-141Crossref PubMed Scopus (1510) Google Scholar7Sessler CN Grap MJ Brophy GM Multidisciplinary management of sedation and analgesia in critical care.Semin Respir Crit Care Med. 2001; 22: 211-225Crossref PubMed Scopus (80) Google Scholar15De Jonghe B Cook D Appere-De-Vecchi C et al.Using and understanding sedation scoring systems: a systematic review.Intensive Care Med. 2000; 26: 275-285Crossref PubMed Scopus (293) Google Scholar A multidisciplinary approach to development is evident in many scales, including MSAT, for which thoughtful construction, review, and revision of the tool by a physician and nurse team is described. Ease of use and of recall is crucial for sustained acceptance of a scale by busy nurses and physicians. The arousal domain of the MSAT is remarkably similar to the sedation component of RASS23Sessler CN Gosnell MS Grap MJ et al.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Am J Respir Crit Care Med. 2002; 166: 1338-1344Crossref PubMed Scopus (2146) Google Scholar and the awakeness domain of the ATICE,24De Jonghe B Cook D Griffith L et al.Adaptation to the Intensive Care Environment (ATICE): development and validation of a new sedation assessment instrument.Crit Care Med. 2003; 31: 2344-2354Crossref PubMed Scopus (138) Google Scholar in which observation for spontaneous behavior is followed by evaluation of response to auditory stimulation, then response to physical stimulation. This approach,23Sessler CN Gosnell MS Grap MJ et al.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Am J Respir Crit Care Med. 2002; 166: 1338-1344Crossref PubMed Scopus (2146) Google Scholar24De Jonghe B Cook D Griffith L et al.Adaptation to the Intensive Care Environment (ATICE): development and validation of a new sedation assessment instrument.Crit Care Med. 2003; 31: 2344-2354Crossref PubMed Scopus (138) Google Scholar which is patterned after the Ramsay Sedation Scale,18Ramsay MA Savege TM Simpson BR et al.Controlled sedation with alphaxalone-alphadolone.BMJ. 1974; 2: 656-659Crossref PubMed Scopus (2212) Google Scholar follows a logical progression and can be performed in 30 s or so, yielding six levels ranging from alert to unresponsive. Further, the levels tend to have little overlap because of the stepwise approach. For example, if the patient opens eyes to auditory stimulation (ie, calling their name), the physical stimulation step is omitted. RASS differs from MSAT and ATICE in that cognition (subject makes eye contact on command) and sustainability are also tested within the sedation scale.23Sessler CN Gosnell MS Grap MJ et al.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Am J Respir Crit Care Med. 2002; 166: 1338-1344Crossref PubMed Scopus (2146) Google Scholar25Ely EW Truman B Shintani A et al.Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).JAMA. 2003; 289: 2983-2991Crossref PubMed Scopus (1095) Google Scholar Ease of use and recall might be adversely affected when more complex testing, such as summing the results of multiple questions or domains22de Lemos J Tweeddale M Chittock D Measuring quality of sedation in adult mechanically ventilated critically ill patients: the Vancouver interaction and calmness scale.J Clin Epidemiol. 2000; 53: 908-919Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar24De Jonghe B Cook D Griffith L et al.Adaptation to the Intensive Care Environment (ATICE): development and validation of a new sedation assessment instrument.Crit Care Med. 2003; 31: 2344-2354Crossref PubMed Scopus (138) Google Scholar or addressing multiple criteria for each level20Riker RR Picard JT Fraser GL Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients.Crit Care Med. 1999; 27: 1325-1329Crossref PubMed Scopus (714) Google Scholar21Devlin JW Boleski G Mlynarek M et al.Motor Activity Assessment Scale: a valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit.Crit Care Med. 1999; 27: 1271-1275Crossref PubMed Scopus (287) Google Scholar is required. Further, the presence of multiple criteria within levels might be confusing if, for example, criteria are met for multiple levels and yet not all criteria from any one level are met.20Riker RR Picard JT Fraser GL Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients.Crit Care Med. 1999; 27: 1325-1329Crossref PubMed Scopus (714) Google Scholar21Devlin JW Boleski G Mlynarek M et al.Motor Activity Assessment Scale: a valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit.Crit Care Med. 1999; 27: 1271-1275Crossref PubMed Scopus (287) Google ScholarSome,20Riker RR Picard JT Fraser GL Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients.Crit Care Med. 1999; 27: 1325-1329Crossref PubMed Scopus (714) Google Scholar21Devlin JW Boleski G Mlynarek M et al.Motor Activity Assessment Scale: a valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit.Crit Care Med. 1999; 27: 1271-1275Crossref PubMed Scopus (287) Google Scholar22de Lemos J Tweeddale M Chittock D Measuring quality of sedation in adult mechanically ventilated critically ill patients: the Vancouver interaction and calmness scale.J Clin Epidemiol. 2000; 53: 908-919Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar23Sessler CN Gosnell MS Grap MJ et al.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Am J Respir Crit Care Med. 2002; 166: 1338-1344Crossref PubMed Scopus (2146) Google Scholar24De Jonghe B Cook D Griffith L et al.Adaptation to the Intensive Care Environment (ATICE): development and validation of a new sedation assessment instrument.Crit Care Med. 2003; 31: 2344-2354Crossref PubMed Scopus (138) Google Scholar but not all18Ramsay MA Savege TM Simpson BR et al.Controlled sedation with alphaxalone-alphadolone.BMJ. 1974; 2: 656-659Crossref PubMed Scopus (2212) Google Scholar validated sedation scales also examine the severity of agitation using subjective criteria. Although point-in-time testing of sedation-agitation scales may demonstrate infrequent (approximately 5 to 10%) agitation among consecutive patient evaluations,23Sessler CN Gosnell MS Grap MJ et al.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Am J Respir Crit Care Med. 2002; 166: 1338-1344Crossref PubMed Scopus (2146) Google Scholar25Ely EW Truman B Shintani A et al.Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).JAMA. 2003; 289: 2983-2991Crossref PubMed Scopus (1095) Google Scholar26Brandl KM Langley KA Riker RR et al.Confirming the reliability of the sedation-agitation scale administered by ICU nurses without experience in its use.Pharmacotherapy. 2001; 21: 431-436Crossref PubMed Scopus (62) Google Scholar agitation is actually a common occurrence, being observed in the majority of ICU patients in prospective case series.27Fraser GL Prato BS Riker RR et al.Frequency, severity, and treatment of agitation in young versus elderly patients in the ICU.Pharmacotherapy. 2000; 20: 75-82Crossref PubMed Scopus (134) Google Scholar Agitation is among the most common indications for sedative therapy.28Rhoney DH Murry KR National survey of the use of sedating drugs, neuromuscular blocking agents, and reversal agents in the intensive care unit.J Intensive Care Med. 2003; 18: 139-145Crossref PubMed Scopus (103) Google Scholar Further, agitation can have important consequences such as self-removal of important tubes and catheters as well as aggressive behavior against caregivers.5Sessler CN Comfort and distress in the ICU: scope of the problem.Semin Respir Crit Care Med. 2001; 22: 111-113Crossref PubMed Scopus (12) Google Scholar29Woods JC Mion LC Connor JT et al.Severe agitation among ventilated medical intensive care unit patients: frequency, characteristics and outcomes.Intensive Care Med. 2004; Google Scholar30Carrion MI Ayuso D Marcos M et al.Accidental removal of endotracheal and nasogastric tubes and intravascular catheters.Crit Care Med. 2000; 28: 63-66Crossref PubMed Scopus (94) Google Scholar31Cohen IL Gallagher TJ Pohlman AS et al.The management of the agitated ICU patient.Crit Care Med. 2002; 30: S97-S125Crossref Scopus (58) Google Scholar32Fraser GL Riker RR Prato BS et al.The frequency and cost of patient-initiated device removal in the ICU.Pharmacotherapy. 2001; 21: 1-6Crossref PubMed Scopus (63) Google Scholar Documenting the presence and intensity of agitation may be useful to assess the response to therapy, to serve as an “alarm” for impending self-removal of medical devices,27Fraser GL Prato BS Riker RR et al.Frequency, severity, and treatment of agitation in young versus elderly patients in the ICU.Pharmacotherapy. 2000; 20: 75-82Crossref PubMed Scopus (134) Google Scholar and to help uncover causative conditions such as unrecognized pain or delirium.7Sessler CN Grap MJ Brophy GM Multidisciplinary management of sedation and analgesia in critical care.Semin Respir Crit Care Med. 2001; 22: 211-225Crossref PubMed Scopus (80) Google Scholar31Cohen IL Gallagher TJ Pohlman AS et al.The management of the agitated ICU patient.Crit Care Med. 2002; 30: S97-S125Crossref Scopus (58) Google Scholar Although agitation (or conversely, calmness) can be assessed as a distinct scale from sedation,22de Lemos J Tweeddale M Chittock D Measuring quality of sedation in adult mechanically ventilated critically ill patients: the Vancouver interaction and calmness scale.J Clin Epidemiol. 2000; 53: 908-919Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar24De Jonghe B Cook D Griffith L et al.Adaptation to the Intensive Care Environment (ATICE): development and validation of a new sedation assessment instrument.Crit Care Med. 2003; 31: 2344-2354Crossref PubMed Scopus (138) Google Scholar some instruments incorporate both, but observe for agitated behavior first.20Riker RR Picard JT Fraser GL Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients.Crit Care Med. 1999; 27: 1325-1329Crossref PubMed Scopus (714) Google Scholar21Devlin JW Boleski G Mlynarek M et al.Motor Activity Assessment Scale: a valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit.Crit Care Med. 1999; 27: 1271-1275Crossref PubMed Scopus (287) Google Scholar23Sessler CN Gosnell MS Grap MJ et al.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Am J Respir Crit Care Med. 2002; 166: 1338-1344Crossref PubMed Scopus (2146) Google Scholar A limitation of this approach is that an agitation rating and a sedation rating cannot technically both be assigned. The issue of two scales within an agitation-sedation scale is made more distinct with RASS by using positive numbers for levels of agitation and negative numbers for levels of sedation, surrounding a level of “0” for calm, alert.23Sessler CN Gosnell MS Grap MJ et al.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Am J Respir Crit Care Med. 2002; 166: 1338-1344Crossref PubMed Scopus (2146) Google ScholarAlthough documentation of agitation is not included in the MSAT, patient movement is evaluated in the second domain, the motor activity scale. To assess the motor activity scale, the patient is observed for 30 s and spontaneous activity is graded on a 4-point scale, ranging from no movement to central truncal movement. Although patient movement is included as a subscale of the comfort scale,33Ambuel B Hamlett KW Marx CM et al.Assessing distress in pediatric intensive care environments: the COMFORT scale.J Pediatr Psychol. 1992; 17: 95-109Crossref PubMed Scopus (565) Google Scholar it is an infrequent target for assessment in sedation scales. In recent work,34Grap MJ, Borchers CT, Munro CL, et al. Actigraphy in the critically ill: correlation with activity, agitation and sedation. Am J Crit Care 2004 (in press)Google Scholar however, continuously recorded limb movement using a small accelerometer correlated well with patient comfort (comfort scale), agitation (RASS), and patient activity, supporting the concept.As with all subjective tools, each sedation scale should demonstrate reliability and validity when tested in clinically relevant patient populations.6Jacobi J Fraser GL Coursin DB et al.Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.Crit Care Med. 2002; 30: 119-141Crossref PubMed Scopus (1510) Google Scholar7Sessler CN Grap MJ Brophy GM Multidisciplinary management of sedation and analgesia in critical care.Semin Respir Crit Care Med. 2001; 22: 211-225Crossref PubMed Scopus (80) Google Scholar15De Jonghe B Cook D Appere-De-Vecchi C et al.Using and understanding sedation scoring systems: a systematic review.Intensive Care Med. 2000; 26: 275-285Crossref PubMed Scopus (293) Google Scholar17Riker RR Fraser GL Monitoring sedation, agitation, analgesia, neuromuscular blockade, and delirium in adult ICU patients.Semin Respir Crit Care Med. 2001; 22: 189-198Crossref PubMed Scopus (38) Google Scholar All of the aforementioned sedation scales have undergone testing of interrater reliability (ie, reproducibility among different testers) with good results.19Riker RR Fraser GL Cox PM Continuous infusion of haloperidol controls agitation in critically ill patients.Crit Care Med. 1994; 22: 433-440Crossref PubMed Scopus (234) Google Scholar20Riker RR Picard JT Fraser GL Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients.Crit Care Med. 1999; 27: 1325-1329Crossref PubMed Scopus (714) Google Scholar21Devlin JW Boleski G Mlynarek M et al.Motor Activity Assessment Scale: a valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit.Crit Care Med. 1999; 27: 1271-1275Crossref PubMed Scopus (287) Google Scholar22de Lemos J Tweeddale M Chittock D Measuring quality of sedation in adult mechanically ventilated critically ill patients: the Vancouver interaction and calmness scale.J Clin Epidemiol. 2000; 53: 908-919Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar23Sessler CN Gosnell MS Grap MJ et al.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Am J Respir Crit Care Med. 2002; 166: 1338-1344Crossref PubMed Scopus (2146) Google Scholar24De Jonghe B Cook D Griffith L et al.Adaptation to the Intensive Care Environment (ATICE): development and validation of a new sedation assessment instrument.Crit Care Med. 2003; 31: 2344-2354Crossref PubMed Scopus (138) Google Scholar25Ely EW Truman B Shintani A et al.Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).JAMA. 2003; 289: 2983-2991Crossref PubMed Scopus (1095) Google Scholar Testing of reliability for SAS and RASS has been particularly rigorous, including comparing nurse, physician, and pharmacist investigators,23Sessler CN Gosnell MS Grap MJ et al.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Am J Respir Crit Care Med. 2002; 166: 1338-1344Crossref PubMed Scopus (2146) Google Scholar both medical and surgical patients,20Riker RR Picard JT Fraser GL Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients.Crit Care Med. 1999; 27: 1325-1329Crossref PubMed Scopus (714) Google Scholar23Sessler CN Gosnell MS Grap MJ et al.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Am J Respir Crit Care Med. 2002; 166: 1338-1344Crossref PubMed Scopus (2146) Google Scholar after implementation of the scale into practice,23Sessler CN Gosnell MS Grap MJ et al.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Am J Respir Crit Care Med. 2002; 166: 1338-1344Crossref PubMed Scopus (2146) Google Scholar25Ely EW Truman B Shintani A et al.Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).JAMA. 2003; 289: 2983-2991Crossref PubMed Scopus (1095) Google Scholar26Brandl KM Langley KA Riker RR et al.Confirming the reliability of the sedation-agitation scale administered by ICU nurses without experience in its use.Pharmacotherapy. 2001; 21: 431-436Crossref PubMed Scopus (62) Google Scholar35Riker RR Fraser GL Simmons LE et al.Validating the Sedation-Agitation Scale with the Bispectral Index and Visual Analog Scale in adult ICU patients after cardiac surgery.Intensive Care Med. 2001; 27: 853-858Crossref PubMed Scopus (196) Google Scholar and at multiple medical centers.20Riker RR Picard JT Fraser GL Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients.Crit Care Med. 1999; 27: 1325-1329Crossref PubMed Scopus (714) Google Scholar23Sessler CN Gosnell MS Grap MJ et al.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Am J Respir Crit Care Med. 2002; 166: 1338-1344Crossref PubMed Scopus (2146) Google Scholar25Ely EW Truman B Shintani A et al.Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).JAMA. 2003; 289: 2983-2991Crossref PubMed Scopus (1095) Google Scholar26Brandl KM Langley KA Riker RR et al.Confirming the reliability of the sedation-agitation scale administered by ICU nurses without experience in its use.Pharmacotherapy. 2001; 21: 431-436Crossref PubMed Scopus (