Semin Neurol 2008; 28(5): 611-630
DOI: 10.1055/s-0028-1105970
© Thieme Medical Publishers

Sedation and Pain Management in Acute Neurological Disease

Marek A. Mirski1 , John J. Lewin2
  • 1Neurosciences Critical Care Unit/Neuroanesthesiology, The Johns Hopkins University, Baltimore, Maryland
  • 2Departments of Pharmacy Services and Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
Further Information

Publication History

Publication Date:
29 December 2008 (online)


The optimum provision of pharmacological sedation of the critically ill neurological patient requires defining the underlying etiology of agitation or need for sedation to determine the optimal agent: pain management, anxiolysis, or treatment of delirium. An appropriate regimen can then be decided upon based on the profiles of action of the several common classes of sedative agents. Methods to both evaluate the efficacy of sedation as well as titration to a predefined clinical goal are important tools toward safe administration of drugs that often have serious adverse effects. Recognition of an individualized approach is also necessary as patients will vary considerably with respect to the kinetics and pharmacodynamics of sedative therapy. The drug classes often selected for sedation in an intensive care unit will be reviewed as well as the metrics by which physicians can achieve their objectives in a safe manner.



Motor Activity Assessment Scale
0UnresponsiveDoes not move with noxious stimulus[*]
1Responsive only to noxious stimuliOpens eyes OR raises eyebrows OR turns head toward stimulus OR moves limbs with noxious stimulus*
2Responsive to touch OR nameOpens eyes OR raises eyebrows OR turns head toward stimulus OR moves limbs when touched or name is loudly spoken
3Calm and cooperativeNo external stimulus is required to elicit movement AND patient is adjusting sheets or clothes purposefully and follows commands
4Restless and cooperativeNo external stimulus is required to elicit movement AND patient is picking at sheets or tubes OR uncovering self and follows commands
5AgitatedNo external stimulus is required to elicit movement AND attempting to sit up OR moves limbs out of bed AND does not consistently follow commands (e.g., will lie down when asked but soon reverts back to attempts to sit up or move limbs out of bed)
6Dangerously agitated, uncooperativeNo external stimulus is required to elicit movement AND patient is pulling at tubes or catheters OR thrashing side to side OR striking at staff OR trying to climb out of bed AND does not calm down when asked

1 Noxious stimulus, suctioning, OR 5 seconds of vigorous orbital, sternal, or nail bed pressure. Adapted from Devlin et al.[19]

Riker Sedation-Agitation Scale (SAS)
7Dangerous agitationPulling at endotracheal tube, trying to remove catheters, climbing over bedrail, striking at staff, thrashing side-to-side
6Very agitatedDoes not calm despite frequent verbal reminding of limits, requires physical restraints, biting endotracheal tube
5AgitatedAnxious or mildly agitated, attempting to sit up, calms down on verbal instructions
4Calm, cooperativeCalm, easily aroused, follows commands
3SedatedDifficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off again, follows simple commands
2Very sedatedArouses to physical stimuli but does not communicate or follow commands, may move spontaneously
1UnarousableMinimal or no response to noxious stimuli, does not communicate or follow commands
Adapted from Riker et al.[17]
Richmond Agitation-Sedation 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 calm
-1DrowsyNot fully alert, but has sustained (> 10 seconds) awakening, with eye contact, to voice
-2Light sedationBriefly (< 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
Adapted from Sessler et al.[20]
AVRIPAS: Revised Sedation Scale
1. Unresponsive to command/physical stimulation1. Difficult to arouse, eyes remain closed
2. Appropriate response to physical stimuli/calm2. Mostly sleeping, eyes closed
3. Mild anxiety/delirium/agitation (calms easily)3. Dozing intermittently, arouses easily
4. Moderate anxiety/delirium/agitation4. Awake, calm
5. Severe anxiety/delirium/agitation5. Wide awake, hyperalert
1. Intubated, no spontaneous effort
2. Respirations even, synchronized with ventilator
3. Mild dyspnea/tachypnea, occasional asynchrony
4. Frequent dyspnea/tachypnea, ventilator asynchrony
5. Sustained, severe dyspnea/tachypnea
Patient Classification Sedation Goal
Acutely ill (weaning not a goal)5–9
Ventilated patient being weaned7–10
Chronic ventilated patient (weaning not a goal)6–9
Nonventilated patient7–9
Adapted from Avripas et al.[22]
Zoom Image

Procedure for Scoring the Minnesota Sedation Assessment Tool (MSAT)

  1. Record the highest level of unstimulated spontaneous motor activity observed in the last 10 minutes.

  2. Walk to the right shoulder and observe eye opening and/or tracking.

  3. If no eye opening, call first name and “open your eyes!”

  4. If no eye opening yet, shake right shoulder firmly, call first name and “open your eyes!”

  5. Choose the arousal scale category appropriate for the patient's response to procedures 2 to 4.

  6. Judge the current quality of the sedation therapy as “adequate,” “oversedated,” or “undersedated.” Use any clinical information available to you in addition to the scale levels.


  • Movement of central muscle group (back or abdominal muscles)

  • Movement of proximal limbs (hip or shoulder)

  • Movement of distal limbs or head and neck muscles

  • No spontaneous movement

Note: Disregard respiratory efforts, cough, swallowing, eye movement, or isolated tiny muscle contractions.


  • Eyes open spontaneously with tracking

  • Eyes open spontaneously, but not tracking

  • Eyes closed, but open to sound of voice

  • Eyes closed, but open to shoulder shake plus sound of voice

  • Eyes stay closed, but other patient movement observed in response to stimulation

  • Eyes stay closed and no patient movement observed in response to stimulation

Adapted from Weinert and McFarland.[25]

Zoom Image

Marek Mirski, M.D. , Ph.D. 

Department of Anesthesiology and Critical Care Medicine, Division of Neuroanesthesia/Neurosciences Critical Care

The Johns Hopkins Hospital, 600 North Wolfe Street, Meyer 8-140, Baltimore, MD 21287