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Pediatric Sedation Scales: Using the Right One When It Counts

By Suzan Miller-Hoover DNP, RN, CCNS, CCRN

“…but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind.” (Lord Kelvin lecture, “Electrical Units of Measurement,” 1893, as cited in Noble, et al.  2005).

Our helpful review of four pediatric sedation scales can help you decide what scale to use

It is hard to imagine that Lord Kelvin’s words from a lecture on electrical units of measurement would be used to enlighten nurses and other medical providers about the value of pain and sedation scales over a century later. However, his words ring true; we need to quantify the level of sedation our patients are experiencing so that treatment can be maximized.  

In 2013, the Society for Critical Care Medicine developed and made available updated sedation guidelines. However, more pediatric research is needed in this area (Shehabi, Bellmo, Mehta, Riker, & Takala, 2013). The goal for sedation in the pediatric intensive care unit (PICU) should be the minimal sedation dose needed for the desired effect. Many patients are over-sedated, resulting in longer ventilator days and increased mortality. We can affect this by diligent nursing care and the use of valid and reliable sedation scales.

This article will review some of the sedation scales that are available for use with pediatric patients: 

•   Pasero Opioid-Induced Sedation Scale (POSS);
•   Ramsay Scale;
•   Richmond Agitation-Sedation Scale (RASS);
•   Aldrete Scoring Tool; and
•   COMFORT Scale.  

Each of these scales has unique characteristics which allow them to be used in specific circumstances.

RELATED CE COURSE: Pain Assessment and Management

The Pasero Opioid-Induced Sedation Scale (POSS)

The Pasero Opioid-Induced Sedation Scale, enables the nurse to determine a patient’s level of sedation before and after the administration of an opioid. A POSS score of S, 1, or 2 indicates an acceptable level of sedation, whereas a score of 3 or 4 indicates over-sedation and the need for a reversal agent. After an opioid is given, the POSS scale is used in conjunction with an age appropriate pain scale (Pasero, 2009). 

If you do not give an opioid, you do not need to use the POSS scale.

 
 Pasero Opioid-Induced Sedation Scale (POSS) with Interventions
SSleep, easy to arouseAcceptable; no action necessary
1Awake and alertAcceptable; no action necessary
2Slightly drowsy, easily arousedAcceptable; no action necessary
3Frequently drowsy, arousable, drifts off to sleep during conversationUnacceptable; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 
4Somnolent, minimal or no response to verbal or physical stimulationUnacceptable; stop opioid; consider administering naloxone3,4; notify prescriber2 or anesthesiologist; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory


(Pasero, C. 2009)

 

Ramsay Scale and Richmond Agitation-Sedation Scale (RASS)

Unlike the POSS scale, the Ramsay Scale and Richmond Agitation-Sedation Scale (RASS) are strictly sedation scales. Use of either of these scales requires the nurse to assess and document the patient’s level of sedation prior to administering a sedative, and again once the sedative has been given, as well as document the patient’s response to the sedative (Ramsay, ND; Richmond Agitation Sedation Scale, ND).

These scales should be used in conjunction with the Aldrete and Modified Aldrete when the patient undergoes procedural sedation.

 
 Ramsay Sedation Scale
1Anxious or restless or bothUnacceptable; increase sedation
2Cooperative, orientated and tranquilAcceptable; no action necessary
3Responding to commandsAcceptable; no action necessary
4Brisk response to stimulusAcceptable; no action necessary
5Sluggish response to stimulusUnacceptable; monitor respiratory status and sedation level until stable at 2 or 3
6No response to stimulusUnacceptable; monitor respiratory status and sedation level until stable at 2 or 3


(Ramsay, M. ND)
(Richmond Agitation Sedation Scale, ND)

 

Aldrete Scoring Tool

The Aldrete Scoring Tool, used for years as a guide to procedural sedation, was originally developed as a guide to determine how the patient is recovering from anesthesia--a recovery readiness score. This scale is used to measure the patient’s readiness to be transferred from the procedural sedation room or post-recovery anesthesia unit to another inpatient room or to be discharged (Aldrete Score Sheet, ND).

These scales should be used in conjunction with the Ramsay and RASS scores to get the full sedation picture.

 

 
 Aldrete Scoring Tool
Activity
Able to move 4 extremities voluntarily or on command2
Able to move 2 extremities voluntarily or on command1
Able to move 0 extremities voluntarily or on command0
Respiration
Able to breathe deeply and cough freely2
Dyspnea or limited breathing1
Apneic0
Consciousness 
Fully awake2
Arousable on calling1
Not responding0
Circulation  
BP + 20% of preanesthetic level2
BP + 20% to 50% of preanesthetic level1

 

 
 Richmond Agitation-Sedation Scale (RASS)
+4CombativeUnacceptable; increase sedation
+3Very agitatedUnacceptable; increase sedation
+2AgitatedUnacceptable; increase sedation
+1RestlessAcceptable; no action necessary
0Alert & calmAcceptable; no action necessary
-1DrowsyAcceptable; no action necessary
-2Light sedationAcceptable; no action necessary
-3Moderate sedationAcceptable; no action necessary
-4Heavy sedationUnacceptable; monitor respiratory status and sedation level until stable at 2 or 3
-5UnarousableUnacceptable; monitor respiratory status and sedation level until stable at 2 or 3

 

BP + 50% of preanesthetic level0
Color
Normal2
Pale, dusky, blotchy, jaundice1
Cyanotic0


(Aldrete Score Sheet, ND)

COMFORT Scale

The COMFORT Scale is a valid and reliable scale for mechanically ventilated patients. When using the COMFORT Scale, no other pain or sedation scale is necessary. The COMFORT Scale measures several parameters to determine if the patient is adequately comfortable or in need of more or less medication to keep them ventilated. Patients with a score between 8 – 17 are over-sedated, scores between 17 – 26 are adequately sedated, and scores between 27 – 40 are under-sedated (COMFORT Scale for Pediatrics, ND).

This scale has not been validated for use in patients who are receiving paralytics.

 

 
 COMFORT Scale
Alertness
Deeply asleep1
Lightly asleep2
Drowsy3
Fully awake and alert4
Hyper-alert5
Calmness/Agitation
Calm1
Slightly anxious2
Anxious3
Very anxious4
Panicky5
Respiratory Response
No coughing, no spontaneous respirations1
Spontaneous respiration, minimal response to ventilator2
Occasional cough or resistance to ventilator3
Actively breathes against the ventilator or coughs regularly4
Fights ventilator coughing or choking5
Physical Movement
No spontaneous movement1
Occasional, slight movement2
Frequent, slight movement3
Vigorous movement in extremities only4
Vigorous movement including torso and head5
Mean Arterial Blood Pressure
Baseline __________Low <_______ High >________
Any observation low1
Baseline2
1-3 deviations high3
4-5 deviations high4
6 deviations high5
Heart Rate
Baseline __________Low <_______ High >________
Any observation low1
Baseline2
1-3 deviations high3
4-5 deviations high4
6 deviations high5
Muscle Tone
Totally relaxed, no tone1
Reduced tone2
Normal tone3
Increased tone with flexion of fingers and toes4
Extreme rigidity and flexion of fingers and toes5
Facial tension
Facial muscles totally relaxed1
Facial muscle tone normal, no tension noted2
Tension evident in some facial muscles3
Tension evident throughout facial muscles4
Facial muscles contorted and grimacing5


(COMFORT Scale for Pediatrics, ND)

 

References
Aldrete Score Sheet (ND). Retrieved from: https://www.easycalculation.com/medical/learn-aldrete-score.php
COMFORT Scale for Pediatrics (ND). Retrieved from: http://img.medscape.com/fullsize/migrated/547/633/pn547633.fig1a.gif 
Noble, B., Clark, D., Meldrum, M., Have, H., Seymour, J., Winslow, M., & Paz, S. (2005). The measurement of pain, 1945-2000. Journal of Pain and Symptom Management; 29:1; 14-21.
Pasero, C. (2009). Assessment of sedation during opioid administration for pain management. Journal of PeriAnesthesia Nursing, 24:3, 186-190.
Ramsay, M. (ND). How to use the Ramsay Score to assess the level of ICU sedation. Retrieved from: http://www.sedationconsulting.com/articles/researcharticles/75-uncategorised/171-how-to-use-the-ramsay-score-to-assess-the-level-of-icu-sedation
Richmond Agitation Sedation Scale. (ND). Retrieved from: http://www.sedationconsulting.com/articles/researcharticles/75-uncategorised/154-richmond-agitation-sedation-scale-rass
Shehabi, Y., Bellmo, R., Mehta, S., Riker, R., & Takala, J. (2013). Intensive care sedation: The past, present and the future. Critical Care; 17, 322.



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