Coma Grading, Scoring Systems and Sedation Practice

Sedating the Patient

Posted by Kai Knudsen, Senior Physician in Anesthesia & Intensive Care. Sahlgrenska University Hospital.
Updated 2019-06-12


Sedation is given according to the patient’s needs and in relation to other ongoing medical treatments. Medications and sedation depth are prescribed with the following objectives:

  • Patient satisfaction
  • Patient safety (e.g., care of surgical wounds, catheters, tubes)
  • Minimal circulatory and respiratory side effects

Drugs for sedation of ICU patients

Propofol (Diprivan®, Propolipid®, Recofol®, Propofol)

Intravenous anesthetic agent; 20 mg/ml. Dosage: 1-3 mg/kg/hour (2-15 ml/h, 20 mg/ml). Normal dose 5-7 ml/h.

Fentanyl (Fentanyl®, Leptanal®)

Intravenous anesthetic agents and analgesics. Solution: 0.05 mg/ml, 50 μg/ml. Dosage: When administering an intensive care patient, the usual dose is 1-2- (4) ml fentanyl intravenously per hour.

Midazolam (Dormicum®)

Intravenous sedation and anxiety disorder benzodiazepine. The usual strength is 1 mg/ml or 5 mg/ml. Dosage: 1-5 ml/h, 1-25 mg/h. Common dose 2-3 ml/h.

Remifentanil (Ultiva®)

Intravenous short-acting opiod for sedation of intensive care patients. Solution 50 μg/ml. The recommended concentration for adult sedation in continuous infusion is 0.05 mg/ml (50 μg/ml). Dosage: 0.01-0.10 μg/kg/min (1-6 ml/hr) at a concentration of 0.05 mg/ml.

Alfentanil (Rapifen®)

Intravenous sedatives and analgesics. Solution 0.5 mg/ml. Dosage: 0.5-3 mg/hour (1-6 ml/hour), at a concentration of 0.5 mg/ml.

Dexmedetomidine (Dexdor®)

Sympatico stimulating agent. Central alpha2 agonist. Provides sedation, reduced heart rate, lowered blood pressure and less stress. Dexmedetomidine is the S-enantiomer of medetomidine.

Dosage: In continuous infusion 0.2-1.4 μg/kg/h. The appropriate starting dose is around 0.7 μg/kg/h for sedation. Solution 100 μg/ml. For continuous infusion dilution to 4 μg/ml alt. 8 μg/ml.

MAAS (Motor Activity Assessment Scale)

MAAS (Motor Activity Assessment Scale) is documented every 3 hours in patients treated with respiratory or CPAP/noninvasive ventilation or spontaneous breath on tub/trach

0:  Unresponsive
1:  Responsive only to noxious stimuli
2:  Responsive to touch or name
3:  Calm and Cooperative
4:  Restless and cooperative
5:  Agitated
6:  Dangerously agitated, uncooperative

Richmond Agitation-Sedation Scale (RASS)

+4CombativeOvertly combative or violent; immediate danger to staff
+3Very agitatedPulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff
+2AgitatedFrequent nonpurposeful movement or patient–ventilator dyssynchrony
+1RestlessAnxious or apprehensive but movements not aggressive or vigorous
±0Alert and calmSpontaneously pays attention to caregiver
-1DrowsyNot fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice
-2Light sedationBriefly (less than 10 seconds) awakens with eye contact to voice
-3Moderate sedationAny movement (but no eye contact) to voice
-4Deep sedationNo response to voice, but any movement to physical stimulation
-5UnarousableNo response to voice or physical stimulation

Different MAAS levels or RASS levels are requested for different patients. Increased sedation (low number) may increase the risk of respiratory and circulatory complications, while patient safety sometimes requires this.

Patient comfort at different degrees of sedation is still relatively unknown. New findings suggest that patients who can clearly remember their intensive care have fewer unpleasant memories (hallucinations, nightmares, paranoid performances) than those who do not remember as well. The RACHEL study found that patients who were deeply sedated for longer times were more affected by hallucinations and nightmares

Target-related sedation

A desired MAAS level or RASS level should be determined for the individual patient every day after discussion in the care team. Most patients are targeted to MAAS level 2 or 3. The doctor prescribes the appropriate MAAS, eg. 2. If the patient is then noted corresponding to MAAS 1, the nurse diminishes the sedative drug until the patient returns to MAAS 2, after which the sedation starts at a lower rate than before.


Cerebral Performance Categories (CPC)

Outcome of Brain Injury: The Glasgow-Pittsburgh Cerebral Performance ScaleOverall Performance Categories
1Good cerebral performance Conscious. Alert, able to work and lead a normal life. May have minor psychological or neurological deficits (mild dysphasia, nonincapacitating hemiparesis, or minor cranial nerve abnormalities).Good overall performance. Healthy, alert, capable of normal life. Good cerebral performance (CPC 1) plus no or only mild functional disability from noncerebral organ system abnormalities.
2Moderate cerebral disabilityConscious. Sufficient cerebral function for part-time work in sheltered environment or independent activities of daily life (dressing, traveling by public transportation, and preparing food). May have hemiplegia, seizures, ataxia, dysarthria, dysphasia or permanent memory or mental changes.Moderate overall disability. Conscious. Moderate cerebral disability alone (CPC 2) or moderate disability from noncerebral system dysfunction alone or both. Performs independent activities of daily life (dressing, traveling, and food preparation). May be able to work part-time in sheltered environment but disabled for competitive work.
3Severe cerebral disabilityConscious. Dependent on others for daily support because of impaired brain function (in an institution or at home with exceptional family effort). At least limited cognition. Includes a wide range of cerebral abnormalities from ambulatory with severe memory disturbance or dementia precluding independent existence to paralytic and able to communicate only with eyes, as in the locked-in syndrome.Several overall disability. Conscious. Severe cerebral disability alone (CPC 3) or severe disability from noncerebral organ system dysfunction alone or both. Dependent on others for daily support.
4Coma, vegetative stateNot conscious. Unaware of surroundings, no cognition. No verbal or psychological interactions with environment.Same as CPC 4
5DeathCertified brain dead or dead by traditional criteria.Same as CPC 5

Glascow Coma Scale (GCS)

A consciousness grading that sums up points from three different reactions, eye opening, verbal response and motor response. Answers below 10 are listed as unconsciousness.

Glasgow Coma Scale    
Score:123456Score
Eye openingNo responseReaction to pain To speechSpontaneously
Verbal answerNo responseIncomprehensible soundsInappropriate wordsConfusedOriented to time, place, person
Motor answerNo responseAbnormal extension (decerebrate)Abnormal flexion (decorticated)Flexion withdrawal from painMoves to localized painObeys commands
Sum of Score:0-3 p: No response3-8: Comatose8-14: Stuporous, drowsy15: Fully awake


Glasgow Outcome Scale (GOS)

The Glasgow Outcome Scale (GOS) is a global functional performance checkpoint that counts the patient’s status into one of five categories: death, vegetative state, severe disability, moderate disability or good recovery. The Extended GOS (GOS) provides more detailed categorization into eight categories by dividing the categories of severe disability, moderate disability and good recovery into a lower and upper category:

1DeathSevere injury or death without recovery of consciousness
2Persistent vegetative stateSevere damage with prolonged state of unresponsiveness and a lack of higher mental functions
3Severe disabilitySevere injury with permanent need for help with daily living
4Moderate disabilityNo need for assistance in everyday life, employment is possible but may require special equipment.
5Low disabilityLight damage with minor neurological and psychological deficits.


Motor Activity Assessment Scale (MAAS)

Level of consciousness is checked and documented every 3 hours in patients treated with respiratory or CPAP/noninvasive ventilation or spontaneous breathing on tube/trach. The MAAS scale is assessed as follows:

0:  Unresponsive
1:  Responsive only to noxious stimuli
2:  Responsive to touch or name
3:  Calm and Cooperative
4:  Restless and cooperative
5:  Agitated
6:  Dangerously agitated, uncooperative

Different MAAS levels are requested for different patients. Increased sedation (low number) may increase the risk of respiratory and circulatory complications, while patient safety sometimes requires this.

Patient comfort at different levels of sedation we still know too little about. New findings suggest that patients who can clearly remember their intensive care have fewer unpleasant memories (hallucinations, nightmares, paranoid performances) than those who do not remember as well. The RACHEL study found that patients who were deeply sedated for longer were more affected by hallucinations and nightmares.

Target-related sedation

A desired MAAS level should be determined for the individual patient every day after discussion in the care team. Most often a level of MAAS 2 or 3 is targeted. The doctor prescribes the appropriate MAAS, eg. 2. If the patient is then noted corresponding to MAAS 1, the nurse reduces the sedative drug until the patient returns to MAAS 2, after which the sedation starts at a lower rate than before.


NEWS

NEWS (National Early Warning Score) is used to assess the adult patient’s (≥ 16 years) vital functions such as breathing, circulation and awareness. NEWS has been developed in the UK. It is a validated instrument for assessing vital parameters that enable early identification of critical illness. The vital parameters consist of: respiratory rate, oxygen saturation, temperature, systolic blood pressure, heart rate and level of consciousness. By comparing different assessment instruments to identify critical illness, NEWS was the best instrument to identify patients in need of intensive care within 24 hours.

Monitoring vital parameters with NEWS

Physiological parameters3210123
Respiratory Rate≤ 89-1112-2021-24≥ 25
Oxygen saturation≤ 9192-9394-95≥ 96
Oxygen administrartionJaNej
Temperature≤ 35.035.1-36.036.1-38.038.1-39.0≥ 39.1
Systolic blood pressure≤ 9091-100101-110111-219≥ 220
Heart rate≤ 4041-5051-9091-110111-130≥ 131
Level of Consciousness AV, P or U

NEWS points should be documented in the medical journal under a separate heading. NEWS points > 5 should be followed by a comment and action, which is doctor’s order.


Reaction Level Scale (RLS)

Definitions

RLS-85

  • RLS 1 Awake. No delayed reaction. Oriented.
  • RLS 2 Drowsy or unclear. Contactable by easy stimulation such as appeal, occasional cry, touch.
  • RLS 3 Very drowsy or unclear. Contactable with powerful stimulation like repeated appeals, shaking, painful stimulation. Can for example keep in mind and fix, obey a call, pronounce single words or ward off pain stimulation.

Limit for unconsciousness

  • RLS 4 Unconscious. Localizes but does not ward off painful stimuli.
  • RLS 5 Unconscious. Withdrawal movement in painful stimuli.
  • RLS 6 Unconscious. Stereotype flexural motion in pain (decortication). Wrist, fingers, elbow bended. The leg is stretched and inverted.
  • RLS 7 Unconscious. Stereotype stretching in pain (decerebration). Opistotonus, extension of the neck, constricted jaws, pronated, adduced, extended arms and legs.
  • RLS 8 Unconscious. No movements to painful stimuli.

 

Awake: Not obtunded, fully oriented, fully awake. Intubated patient: No evidence of delayed response.

Lethargic: The patient is assessed as lethargic (drowsy) if he/she feels or participates poorly, and responds or reacts with a delayed response.

Unclear: The patient is unclear if he/she answers wrongly any of the following three questions;

a) “What is your name?” (first and last name)

b) “Where are you?” (place e.g. city name or “hospital’s name”)

c) “What year and what month is it now?”

Responsive: May be awakened. The patient can do any of the following: Make conversations or pronounce words – follow your eyes – obey – ward off pain.

Follow with the eyes: Eye-catching with a response and at some point clearly try to keep a steady look into your eyes.

Follow demands: On call, the patient performs a specific movement, for example: “lift your arms”, “stretch your tongue” or “close your eyes”.

Warding pain: The patient locates pain stimulation, actively grips and tries to remove noxious stimulus.

Unconscious: Cannot be woken up. Unable to perform any tasks on demand.

Localize pain: The patient is examined as he lies on his back with his arms resting in the bed along the sides of the body. a) In pain stimulation at the jaw angle of the patient any hand above the cheek level or b) during pain stimulation of the nail bed on one hand movement of the patient’s other hand across the middle line.

Withdrawal movements: a) During pain stimulation at the jaw angle, the patient turns the face away or b) During pain stimulation against the nail bed, the patient does not locate the pain but clearly withdraws his arm away from the pain.

Stereotype bending movements: During pain stimulation, the patient bends slowly the elbow and the wrist, but cannot locate or withdraw any limbs.

Stereotype stretching movements: During pain stimulation, the patient stretches his arms or legs. If both bending and stretching movements occurs, bend movement is noted, i.e. the best answer applies.

Unresponsive to pain stimuli: The patient does not move arms or legs or grimace during pain stimulation.


Richmond Agitation-Sedation Scale (RASS)

Documented every 3 hours in patients treated with respiratory or CPAP/noninvasive ventilation or spontaneous breathing on tube or tracheal cannula.

RASS is assessed according to the following scale:

+4CombativeOvertly combative or violent; immediate danger to staff
+3Very agitatedPulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff
+2AgitatedFrequent nonpurposeful movement or patient–ventilator dyssynchrony
+1RestlessAnxious or apprehensive but movements not aggressive or vigorous
±0Alert and calmSpontaneously pays attention to caregiver
-1DrowsyNot fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice
-2Light sedationBriefly (less than 10 seconds) awakens with eye contact to voice
-3Moderate sedationAny movement (but no eye contact) to voice
-4Deep sedationNo response to voice, but any movement to physical stimulation
-5UnarousableNo response to voice or physical stimulation

Procedure for RASS assessment

  1. Observe the patient. Is the patient alert and calm (0 points)? Does the patient exhibit behavior that is consistent with restlessness or agitation (score +1 to +4 using criteria under description)?
  2. If the patient is not alert, pronounce with the loud voice the patient’s name and urge the patient to open his eyes and look at the speaker. Repeat once, if necessary. Try to persuade the patient to continue to rely on the speaker. The patient opens his eyes and has eye contact, which is maintained for more than 10 seconds (points -1). The patient opens his eyes and has eye contact, but is not maintained for 10 seconds (points -2). The patient makes some form of movement in response to speech but no eye contact (score -3).
  3. If the patient does not respond to the call, physically stimulate the patient by shaking the shoulders and then rub the sternum if response does not occur when shaking shoulders. The patient has some form of movements responsive to physical stimulation (score -4). The patient gives no response to speech or physical stimulation (points -5).

Different RASS levels are demanded for different patients. Increased sedation (low scoring) may increase the risk of respiratory and circulatory complications, while patient safety sometimes requires more sedation. Patient comfort at different levels of sedation we still know too little about. New findings suggest that patients who can clearly remember their intensive care have fewer unpleasant memories (hallucinations, nightmares, paranoid performances) than those who do not remember as well. The RACHEL study found that patients who were deeply sedated for longer periods were more affected by hallucinations and nightmares.

Target-related sedation

A desired MAAS level should be determined for the individual patient every day after discussion in the care team. Most often a level of MAAS 2 or 3 is targeted. The doctor prescribes the appropriate MAAS, eg. 2. If the patient is then noted corresponding to MAAS 1, the nurse reduces the sedative drug until the patient returns to MAAS 2, after which the sedation starts at a lower rate than before.


Confusion Assessment Method for the ICU (CAM-ICU)

CAM-ICU is a quick way to clinically estimate the presence of delirium in an intensive care patient. One assesses four different mental recognition signs.

Characteristics 1: Acute appearance or fluctuating course.

Is the patient’s mental status changed compared with the patient’s previous status? Or

Are there any signs of mental status change over the past 24 hours as shown in the censorship scale fluctuations (ie, RASS, MAAS), RLS 85, GCS or previous delirium assessment.

If no; CAM-ICU is assessed as negative – no delirium.

If yes: Characteristics 2. Inattention.

ASE letter test: Tell the patient: “I will now read 10 letters in sequence. Every time you hear the letter A, hug my hand. “Read the letters SAVEAHAART in normal tone mode at 3-second intervals. Incorrect response: No handshake at letter A or handshake in other letters. If now 0-2 error: CAM-ICU negative – no delirium.

More than 2 errors:

Characteristics 3: Changed consciousness level.

Occurre if RASS is anything other than 0 or MAAS is anything other than 3. If RASS is other values than 0: CAM-ICU positive – delirium. MAAS other than 3: CAM-ICU positive – delirium.

About RASS = 0:

Characteristics 4: Inconsistent thoughts.

Answer the following questions:

  1. Can a stone float in water?
  2. Are there any fish in the ocean?
  3. Weighs one kilo more than two kilos?
  4. Do you use hammer to hit the nail?

On command (tell the patient)

  1. “Hold up as many fingers as I do.” (Show two fingers in front of the patient).
  2. “Do the same thing with your other hand.” (Without holding up two fingers).
  3. If the patient cannot move both arms, ask the patient instead: “Hold up another finger”.

More than 1 error: CAM-ICU positive – delirium.

0-1 error: CAM-ICU negative – no delirium.

ICU delirium = Characters 1 and 2 appear together with signs 3 or 4.


Fisher Scale (modified) – SAH

Grade 1no subarachnoid (SAH) or intraventricular haemorrhage (IVH) detected
incidence of symptomatic vasospasm: 21% 
Grade 2diffuse thin (<1 mm) SAH
no clots
incidence of symptomatic vasospasm: 25%
Grade 3localised clots and/or layers of blood >1 mm in thickness
no IVH
incidence of symptomatic vasospasm: 37%
Grade 4diffuse or no SAH
ICH or IVH present
incidence of symptomatic vasospasm: 31%


Hunt & Hess / WFNS grading

Clinical grading in subarachnoidal bleeding.

The Hunt and Hess scale describes the severity of subarachnoid haemorrhage, and is used as a predictor of survival.

Mild Headache, Alert and Oriented, Minimal (if any) Nuchal Rigidity+1
Full Nuchal Rigidity, Moderate-Severe Headache, Alert and Oriented, No Neuro Deficit (Besides CN Palsy)+2
Lethargy or Confusion, Mild Focal Neurological Deficits+3
Stuporous, More Severe Focal Deficit+4
Comatose, showing signs of severe neurological impairment (ex: posturing)+5
Grade 1Asymptomatic or minimal headache and slight neck stiffness70% survival
Grade 2Moderate to severe headache; neck stiffness; no neurologic deficit except cranial nerve palsy60% survival
Grade 3Drowsy; minimal neurologic deficit50% survival
Grade 4Stuporous; moderate to severe hemiparesis; possibly early decerebrate rigidity and vegetative disturbances20% survival
Grade 5Deep coma; decerebrate rigidity; moribund10% survival