What does "off shock" mean in clinical practice?

"Off Shock" Clinical Definition

"Off shock" is clinical shorthand meaning the patient has been successfully resuscitated from shock and no longer exhibits signs of inadequate tissue perfusion—specifically, they have restored normal mental status, capillary refill ≤2 seconds, normal pulse quality, warm extremities, adequate urine output (>1 mL/kg/h), and normalized blood pressure without requiring escalating vasopressor support. 1, 2

Core Clinical Criteria for Being "Off Shock"

Perfusion markers must normalize:

• Capillary refill time ≤2 seconds (not prolonged as in cold shock, nor flash refill as in warm shock) 1, 2
• Normal mental status (alert and oriented, not confused, lethargic, or irritable) 2
• Normal pulse quality (neither weak/thready nor bounding) 2
• Warm extremities without mottling 1, 2
• Urine output >1 mL/kg/h 1, 2

Hemodynamic parameters must stabilize:

• Normal blood pressure for age (systolic ≥90 mmHg in adults, age-appropriate in children) without requiring increasing vasopressor doses 1, 3
• Mean arterial pressure (MAP) ≥65 mmHg in adults or age-appropriate MAP in children 4, 3
• Central venous oxygen saturation (ScvO₂) >70% if central access is available 1, 3
• Normal perfusion pressure (MAP minus central venous pressure) for age 1, 3

Vasopressor trajectory matters:

• Vasopressors are being weaned or discontinued (not escalating or requiring additional agents) 4, 3
• Patient maintains stability on decreasing support rather than requiring catecholamine-resistant shock interventions 1

Distinguishing "Off Shock" from Ongoing Shock States

The American College of Critical Care Medicine defines specific shock states that indicate the patient is not "off shock":

• Fluid-refractory/dopamine-resistant shock: Shock persists despite ≥60 mL/kg fluid resuscitation and dopamine infusion to 10 μg/kg/min 1
• Catecholamine-resistant shock: Shock persists despite direct-acting catecholamines (epinephrine or norepinephrine) 1
• Refractory shock: Shock persists despite goal-directed inotropes, vasopressors, vasodilators, and metabolic/hormonal homeostasis 1, 2

Practical Clinical Application

When documenting or communicating that a patient is "off shock," you are asserting:

• All clinical perfusion endpoints have been met (capillary refill, mental status, pulse quality, extremity warmth, urine output) 1, 2
• Hemodynamic goals are achieved (normal BP, MAP ≥65 mmHg, ScvO₂ >70%) 4, 3
• Vasopressor support is stable or decreasing (not escalating to additional agents or higher doses) 4, 3
• The patient no longer requires aggressive shock resuscitation protocols (no further fluid boluses, no addition of rescue therapies like ECMO) 1, 3

Common Pitfalls

Do not declare a patient "off shock" based solely on blood pressure normalization:

• Hypotension is not required to define shock, and conversely, normal blood pressure alone does not confirm adequate tissue perfusion 5
• Assess all perfusion markers (mental status, capillary refill, urine output, lactate clearance) before concluding shock has resolved 2, 5

Beware of compensated shock masquerading as stability:

• Tachycardia with normal blood pressure may represent compensated shock with high systemic vascular resistance, not true resolution 2
• Persistent elevated lactate despite normalized vital signs indicates ongoing tissue hypoperfusion 5

Ensure vasopressor weaning is sustainable:

• A patient transiently stable on high-dose vasopressors is not "off shock" until support can be reduced without clinical deterioration 4, 3