Clinical scoring systems

The methods fulfilling most of the demands of ICU sedation monitoring for routine use are objective clinical sedation scoring systems. These scoring systems are based on the principle that easily recognizable elements of sedation are weighted by a number, and the sedation score is given by this number or a sum of numbers related to several of these elements. Several scores have been developed in the last 25 years. Some are intended for subpopulations of critically ill patients, and sedation scores should not be confused with scores designed for other purposes, such as the Glasgow Coma Scale, whose clinical use should be restricted to describing the degree of consciousness.

Two scoring systems, the Ramsay sedation score and the Cambridge sedation score (also known as the Addenbrooke's sedation score), have survived the test of time and are in widespread use. The Ramsay Score, which was developed in 1974, consists of two parts: the awake levels and the asleep levels ( Table..!). The arousability from sleep levels is tested by recording the response to verbal command or, if there is none, the response to a firm glabellar tap ( Hansen-Flaschen §L§L

1994). In the Cambridge sedation score (Ta.ble 2.) the patient's response to the unstandardized but strong stimulus of tracheal suction is recorded if there is no reaction to verbal stimuli. The observers also register whether the patient is paralyzed or in a normal sleeping state ( Shel|.y,,,and, Wa.Og 1992). The UCL Hospitals sedation score (Table,3) is a modification of the Cambridge sedation score (Sjinger,iand,,iWe.b.b.,.19.9.Z). To avoid oversedation due to increased sedation in an attempt to abort cough produced by suction, this score replaces response to tracheal suction with response to movement or noxious stimuli. The UCL sedation score also denominates the sedation scores with increasing negative or positive values which indicate over- and undersedation respectively. This method may be of didactic value, as the principle of titrating sedation near a score of zero and avoiding extreme values is easy for nursing staff to understand. The sedation elements of these tests should be interpreted equally easily by doctors and nurses, are not time-consuming, are not drug specific, and give valid information about the sedation level by a single number. However, neither test differentiates between different elements of sedation. This is better achieved by the COMFORT scale developed for use in sedated children which combines the scores of eight clinical variables ( Ambuelefa/ 1992). Adaptation of this score to adult patients is simple.

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Table 1 Ramsay sedation score

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Table 2 Cambridge sedation score

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Table 3 UCL Hospitals sedation score.

A common limitation of all clinical sedation scores is that they do not differ between sedation induced by drugs and decreased level of consciousness due the patient's illness or decreased patient response due to major depression. The existing sedation scores are, in effect, an integrated score of drug-induced sedation and somnolence (Hansen-FlascheD §L§L 1994). Even so the scores are adapted to clinical use but more specific methods for scientific studies of sedating drug efficacy are absent. Another limitation of categorized sedation scores is that it is not possible to assume that the intervals between the scores are equal; therefore, for scientific purposes, the scores must be treated as non-parametric data.

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