Ramsay Sedation Scale

Overview

The Ramsay Sedation Scale was introduced in 1974 as one of the earliest standardised tools to describe sedation depth in ICU patients. Originally developed for use with alphaxalone-alphadolone anaesthesia, it gained widespread adoption in intensive care and procedural sedation settings worldwide. Although newer scales such as RASS have largely superseded it in contemporary guidelines, the Ramsay Scale remains in common use in many institutions and clinical trials.

Scale

Level	State	Clinical Signs
1	Awake – anxious/agitated	Patient anxious, agitated, or restless
2	Awake – cooperative	Patient cooperative, oriented, and tranquil
3	Awake – responds to commands only	Patient responds to commands only
4	Asleep – brisk response	Brisk response to loud auditory stimulus or light glabellar tap
5	Asleep – sluggish response	Sluggish response to loud auditory stimulus or glabellar tap
6	Asleep – no response	No response to loud auditory stimulus or glabellar tap

Assessment & Targets

For most mechanically ventilated ICU patients a target of Level 2–3 is appropriate, providing adequate comfort while allowing interaction and ventilator synchrony. Level 4–5 may be indicated for procedures, high-PEEP ventilation, or patient transport. Level 6 indicates excessively deep sedation and is generally not a therapeutic target.

Level 1 indicates inadequate sedation requiring analgesic or anxiolytic optimisation before increasing sedation depth.

Comparison to RASS

Ramsay Level	Approximate RASS Equivalent
1	+1 to +2 (restless / agitated)
2	0 (alert and calm)
3	−1 (drowsy)
4	−2 (light sedation)
5	−3 (moderate sedation)
6	−4 to −5 (deep sedation / unarousable)

Literature

Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. BMJ. 1974;2(5920):656–659.

De 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(9):2344–2354.