Sedation/Analgesia, CICU and PICU, Mechanically Ventilated Patient — State Behavioral Scale (SBS) — Clinical Pathway: ICU

Sedation/Analgesia, CICU and PICU, Mechanically Ventilated Patient — State Behavioral Scale (SBS) — Clinical Pathway: ICU

State Behavioral Scale (SBS)

  • SBS may be used for patients receiving sedation
  • Score as patient's response to voice, then touch, then noxious stimuli
  • Planned ETT suctioning or < 5 sec of nail bed pressure
  • SBS Scores Procedure
  • SBS Scoring Job Aid
Score Description Definition
-3 Unresponsive
  • No spontaneous respiratory effort
  • No cough or coughs only with suctioning
  • No response to noxious stimuli
  • Unable to pay attention to care provider
  • Does not distress with any procedure (including noxious)
  • Does not move
-2 Responsive to
Noxious Stimuli
  • Spontaneous yet supported breathing
  • Coughs with suctioning/repositioning
  • Responds to noxious stimuli
  • Unable to pay attention to care provider
  • Will distress with a noxious procedure
  • Does not move/occasional movement of extremities or shifting of position
-1 Responsive to
Gentle Touch or Voice
  • Spontaneous but ineffective non-supported breaths
  • Coughs with suctioning/repositioning
  • Responds to touch/voice
  • Able to pay attention but drifts off after stimulation
  • Distresses with procedures
  • Able to calm with comforting touch or voice when stimulus removed
  • Occasional movement of extremities or shifting of position
0 Awake and Able to Calm
  • Spontaneous and effective breathing
  • Coughs when repositioned/occasional spontaneous cough
  • Responds to voice/no external stimulus is required to elicit response
  • Spontaneously pays attention to care provider
  • Distresses with procedures
  • Able to calm with comforting touch or voice when stimulus removed
  • Occasional movement of extremities or shifting of position/increased movement
    (restless, squirming)
+1 Restless and
Difficult to Calm
  • Spontaneous effective breathing/having difficulty breathing with ventilator
  • Occasional spontaneous cough
  • Responds to voice/no external stimulus is required to elicit response
  • Drifts off/spontaneously pays attention to care provider
  • Intermittently unsafe
  • Does not consistently calm despite 5-minute attempt/unable to console
  • Increased movement (restless, squirming)
+2 Agitated
  • May have difficulty breathing with ventilator
  • Coughing spontaneously
  • No external stimulus required to elicit response
  • Spontaneously pays attention to care provider
  • Unsafe (biting ETT, pulling at lines, cannot be left alone)
  • Unable to console
  • Increased movement (restless, squirming or thrashing side-to-side, kicking legs)

Pain Scales

FLACC Term NB to 7 yrs
FACES ≥ 3 yrs, able to self-report
Numeric Rating Scale > 5 yrs
SBS
Pediatric patients on mechanical ventilation
Response to stimuli, 6 point scale

WAT-1 should only be utilized when actively weaning sedation and at the time of extubation or placement of tracheostomy.