Niki Hester
Maureen Clifford
Heather Woodard
Jennifer Stephens

Define delirium and how delirium impacts the patient.

State the purpose of daily interruption of sedation (DIS).

Describe RASS and explain range.

Accurately rate the hypothetical patient using the RASS
scale.

Answer questions about the RASS.

Commit to using the RASS.
 The
ICU is an environment with alarms, constant light
and frequent interruptions, causing sleep deprivation.
The patients have many tubes, pain and anxiety.
 Delirium,
or “ICU psychosis” develops in 60 to 80%
of ventilated ICU patients and 20 to 50% of nonventilated patients.
 Delirium
is a global impairment of the cognitive
processes, usually of sudden onset, with
disorientation, impaired memory, altered sensory
perceptions, and, at times, inappropriate behavior.
Delirium is reversible.
 Common
causes of delirium include medical
conditions, substance intoxification or withdrawal, and
medications. PAIN is also a cause of delirium.
 Consequences
of delirium include increased reintubation rates, prolonged hospital length of stay,
increased cost, prolonged neurocognitive impairment,
and an increased risk of death.
 Analgesics
and sedatives are needed to maintain
patient safety and comfort, and are used in treatment of
delirium. Oversedating or undersedating these patients
can have significant adverse affects.

Also known as “sedation vacation”

The purpose is to interrupt the patient’s sedation by turning
their sedation off once daily.

This helps to avoid sedative dependence and withdrawls,
and has been shown to decrease the patient’s duration of
mechanical ventilation and length of stay (LOS).

The patient awakens, and assessment of level of
consciousness and neurologic function are performed
utilizing the Richmond Agitation and Sedation Scale.

DIS is also used as an adjunct intervention for the
reduction of ventilator associated pneumonia (VAP).

Active seizures

Alcohol withdrawl or delirium tremors

Increased intracranial pressure

Neuromuscular blockade

Uncontrolled arrhythmias

Myocardial infarction within previous 24 hours

Palliative care patients

MD order
Is a DIS
contraindicated?
NO
YES
Is analgesia being
used for pain?
YES
STOP
NO
DIS = Turn sedation
& analgesia off
Manage pain
prior to
turning off
sedation
YES
Turn off
sedation
Did the
patient
tolerate DIS
NO
RCP to
perform
SBT
Consider bolus
dose, prn dosing
or restart
sedation at 50%
of previous level
Able to
extubate
patient
Reevaluate SAS
score for
appropriateness
YES
Collaborate
with MD & RCP
NO
Does
patient
require
sedation?
NO
DO NOT restart
sedation, continue to
monitor pt
YES
Is patient at ordered
level?
Consult Sedation
Mangement Job Aid
Consider PRN dosing
Consider delirium
NO
YES
Continue present
treatment and
attempt DIS in 24
hours
 Richmond Agitation

and Sedation Scale
Research has shown that excessive sedation can
prolong the use of mechanical ventilation, create
physical and psychological dependence, and increase
the length of the hospital stay.
 The
RASS scale is an assessment tool that measures the
sedation or agitation of ICU patients, which assists
healthcare providers in titrating sedative medications.
 The
RASS is a ten-point scale with zero as the neutral
position. Positive numbers measure agitation, while
negative numbers measure sedation.
 The
significance of RASS is to maintain a balance
between patient comfort and interaction with the
environment, ensuring that patients are maintained on
the least amount of sedation as possible. The goal is a
zero or negative one on the RASS scale.
 Literature
supports notion that inadequate and/or
excessive sedation and analgesia are still common in
Intensive Care Units despite Joint Commission
mandating use of sedation scales.

Failure to meet goals of proper sedation and analgesia can
have detrimental effects including an increase in adverse
events, poor outcomes, longer ICU stays and financial
burdens.

Studies have shown better outcomes and cost savings with
the implementation of sedation protocols.

Patients who were aroused/woken up on a daily basis
during their ICU stay were shown to have a shorter LOS
and a shorter duration of mechanical ventilation.
Optimal sedation level that provides comfort while
maintaining patient interaction with the environment.
Daily goal = arousable, comfortable sedation
RASS goal = 0 or -1
 Aim
of Study: Examine and compare the reliability and
validity of three scales (Sedation and Agitation Scale, Richmond
Agitation and Sedation Scale & Visual Analog Scale) used for
measuring sedation and agitation levels and determine which
one was the most reliable and accurate for use in the ICU
 Study
Population: Observations were conducted on 79
patients by a total of 25 nurses and four physicians who were
unfamiliar with the scales.
 Results: RASS had an excellent reliability (r>0.86) with high
coefficients noted between the research team nurse and unit
physician (r=0.91). The RASS also had higher correlations when
compared to the SAS and VAS which means the RASS is a reliable
and valid tool for measuring states of sedation and agitation in
general ICUs
 Objective:
Look at the current literature regarding
daily sedation interruption (DSI) and determine its
pros and cons.
 Findings:
DIS patients were extubated quicker than
conventional sedation management, discharged from
the ICU quicker, and had fewer expensive
neurological investigations (CT, EEG). It is also
suggested that pain and anxiety are the predictable
adverse effects of DIS as patients wake from coma.
 Aim
of Study: Determine the validity and reliability of the
Richmond agitation and sedation scale in relation to ease of
use as well as accuracy of determining an appropriate level of
sedation for the patient.
 Study
Population: Sample size included 172 patients of
various conditions in different types of intensive care units.
 Results: Indicated that the RASS had a high correlation of
inter-rater reliability, with all five raters having the RASS score
within 1 point of each other in more than 95% of cases. The
study suggests that the Richmond Agitation and Sedation Scale
is not only easy to use, but is accurate, and has a high interrater reliability across a wide variety of intensive care unit
patients, further enhancing generalizability.
 That’s
Right! It’s Time For…
Delirium and DIS
RASS
Research
10
10
10
20
20
20
30
Delirium and DIS - 10
• Name 3 consequences of delirium.
Delirium and DIS Answer – 10
- increased reintubation rates
- prolonged hospital stay
- increased cost
- increased risk of death
- prolonged neuro-cognitive impairment after
discharge
Delirium and DIS - 20
• Name 3 contraindications for Daily
Interruption of Sedation (DIS)?
Delirium and DIS Answer – 20
 - active seizures
 -alcohol withdrawal/ detox
 - increased intracranial pressure
 -neuromuscular block
 -uncontrolled arrhythmias
 - MI within previous 24hours
 - high frequency oscillating ventilation
 - hypothermia protocol
 - palliative care
 - MD Order
RASS - 10
• What are some advantages of the Richmond
Agitation and Sedation Scale compared with
other sedation assessments?
RASS Answer – 10
ease of use, accuracy, and high inter-rater
reliability
RASS - 20
• What is the goal of sedation?
RASS Answer – 20
- arousable, yet comfortable sedation
- a score of -1 to 0 on the RASS
- a balance between sedation and pain
management
Research - 10
• Positive ratings on Richmond agitation &
sedation scale indicate ___________while
negative ratings indicate ___________.
Research Answer – 10
agitation; sedation
Research - 20
• Why is the Richmond Agitation and Sedation
Scale the best scale for measuring agitation
and sedation?
Research Answer – 20
High validity and reliability
Research - 30
• What are some of the benefits of using DIS?
Research Answer – 30
DIS patients were extubated quicker than
conventional sedation management,
discharged from the ICU quicker, and had
fewer expensive neurological investigations
(CT, EEG)
You All Win!!

It is possible to wean from sedation, even if the patient can
not be weaned from the ventilator.

RN & RCP should collaborate on timing of DIS & SBT

Goal is to maintain the patient on the least amount of
sedation that is medically appropriate

Lighten sedation to appropriate wakefulness daily.

Assess sedation using RASS per hospital protocol (usually
q4h and prn).

RASS goal should be reevaluated daily.
Discuss
the significance of using a
standardized tool to assess the ICU patient.
Discuss
the value of using the RASS tool to
benefit the patient.
In our presentation we…

Defined delirium and its impact on ICU patients.

Stated the purpose of the daily interruption of sedation
(DIS).

Described RASS scale and explained its continuum/range.

Demonstrated use of RASS scale using hypothetical patient
scenario.

Encouraged commitment to using RASS when determining
patients level of agitation or sedation.
Bastable, S. B. (2008). Nurse as educator: Principle of
teaching and learning for nursing practice (3rd ed.).
Boston, MA: Jones and Bartlett Publishers.
Delirium Committee, Sentara Norfolk General Hospital.
(2011). Detecting and managing delirium in the ICU.
Norfolk, VA.
O’Connor, M., Bucknall, T., & Manias, E. (2008). A critical
review of daily sedation interruption in the intensive care
unit. Journal of Clinical Nursing, 18, 1239-1249.

Rassin, M., Sruyah, R., Kahalon, A., Naveh, R., Nicar, I. &
Silner, D. (2007) Between the fixed and changing:
examining and comparing reliability and validity of
three sedation-agitation measuring scales.
Dimensions of Critical Care Nursing, 26, 76-82.

Robinson, B. R., Mueller, E. W., Henson, K., Branson, R.
D., Barsoum, S., & Tsuei, B. J. (2008). An analgesiadelirium-sedation protocol for critically ill trauma
patients reduces ventilator days and hospital length of
stay. Journal of Trauma, Injury, Infection, and
Critical Care, 65, 517-526. doi:
10.1097/TA.0b013e318181b8f6
 Sessler,
C. N., Gosnell, M. S., Grap, M. J., Brophy,
G. M., O’Neal, P. V., Keane, K. A.,…Elswick,
R.K. (2002). The richmond agitation-sedation
scale: Validity and reliability in adult intensive
care unit patients. American Journal of
Respiratory and Critical Care Medicine, 166,
1338-1344. Retrieved from
http://171.66.122.149/cgi/reprint/166
 Urden,
L. D., Stacy, K. M., Lough, M. E. (2010).
Critical care nursing (6th ed.). St. Louis, MO:
Mosby Elsevier.
THE END