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

Abstract

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.