A Novel Approach to Early Personalized Hemodynamic Resuscitation: Non-Invasive Peripheral Photoplethysmography for Identifying Predominant Vasodilatory Shock in Sepsis.

INTRODUCTION

Sepsis remains a leading cause of mortality, with mortality from septic shock exceeding 40%. Standardized resuscitation (30 mL/kg) may cause adverse outcomes, including fluid overload or prolonged hypotension, emphasizing the need for individualized strategies. Sepsis-induced shock arises from varying degrees of vasodilation and hypovolemia, yet patients often present with similar clinical signs in the emergency department (ED). Photoplethysmography (PPG), a non-invasive technique reflecting peripheral perfusion, may help identify patients with a predominant vasodilatory profile who could benefit from early vasopressor therapy.

METHODS

This post hoc analysis used data from the Acutelines biobank at the University Medical Centre Groningen. Adults admitted for non-trauma specialties with suspected infection and hemodynamic instability (MAP < 70 mmHg, SBP < 90 mmHg, shock index > 0.9, or lactate > 4.0 mmol/L) were included. PPG data were pre-processed and features extracted. Principal component analysis (PCA) and K-means clustering enabled dimensionality reduction and hemodynamic profiling. Logistic regression assessed the discriminative performance of PPG-based models for vasopressor therapy initiation within 24 h.

RESULTS

Among 325 patients, 16.3% received vasopressors. PCA identified three principal components explaining 80.3% of variance: PC1 (arterial compliance), PC2 (cardiac output and systemic vascular resistance), and PC3 (peripheral vasomotor tone). The PPG-based model showed moderate discriminative power (AUROC: 0.75), improving when combined with MAP and lactate (AUROC: 0.83).

CONCLUSION

PPG enables identification of patients likely to benefit from vasopressor therapy during the first 20 min after ED arrival. By providing additional insight into peripheral perfusion, this proof-of-principle study supports further exploration of PPG as a clinical support tool for personalized hemodynamic resuscitation in sepsis.

EDITORIAL COMMENT: This secondary analysis demonstrates early peripheral circulatory patterns in sepsis using photoplethysmography at the start of resuscitation. Distinct PPG-derived profiles were associated with vasopressor initiation within 24 h, supporting PPG as a tool for personalized resuscitation.