Journal Publication

Perfusion-guided fluid strategy cuts skin failure in elderly ICU patients

A 204-patient randomized trial found targeting peripheral perfusion during fluid resuscitation nearly halved acute skin failure in elderly critically ill patients, though the effect did not extend to 28-day mortality.

A randomized controlled trial found that a peripheral perfusion index (PPI)-guided fluid resuscitation strategy reduced 7-day acute skin failure in elderly critically ill patients compared with conventional fluid management.

By AppliedXLJuly 18, 2026

Executive Summary

A randomized trial in elderly critically ill patients found that guiding fluid resuscitation by a peripheral perfusion measurement lowered the rate of acute skin failure within the first week of intensive care compared with standard fluid management.
The result gives intensivists a noninvasive, bedside perfusion target to layer onto existing macrohemodynamic resuscitation goals, rather than introducing a new drug or device.
The same trial found no difference in short-term mortality between the two strategies, and skin failure that did occur in the perfusion-guided group took longer to appear rather than being fully prevented.
Patients managed with the perfusion-guided approach cleared lactate faster in the first six hours and accumulated less excess fluid over three days, both markers of tighter resuscitation quality that reinforce the primary result.

The stake

Acute skin failure, a form of tissue breakdown linked to inadequate peripheral perfusion, is a marker clinicians watch in elderly patients undergoing aggressive fluid resuscitation in the intensive care unit. The trial tested whether adding a peripheral perfusion index (PPI) target of at least 1.4 to standard macrohemodynamic resuscitation goals would reduce that risk, against fluid management guided only by routine indicators. Because PPI is measured noninvasively at the bedside, the approach requires no new drug or device beyond monitoring already available in many intensive care units. Effect

How it was done

The study was a prospective, randomized, parallel-controlled trial that enrolled 216 elderly critically ill patients requiring early active fluid resuscitation between January and December 2025, with 204 patients (103 intervention, 101 control) analyzed on an intention-to-treat basis. Patients were randomized to a PPI-guided resuscitation strategy, using PPI of at least 1.4 as an added endpoint alongside conventional targets, or to conventional fluid management driven by routine indicators alone. The prespecified primary outcome was the incidence of acute skin failure within 7 days of intensive care unit admission, with secondary outcomes covering time to skin-failure onset, resuscitation quality markers, organ function, and longer-term prognosis including 28-day mortality. Effect

The result

Acute skin failure within 7 days occurred in 14.6% of the PPI-guided group (15 of 103 patients) versus 29.7% of the conventional-care group (30 of 101 patients), a difference of 15.1 percentage points (P =.009). Among patients who did develop skin failure, the median time to onset was longer in the PPI-guided group, 5.2 days versus 3.1 days (log-rank P =.012), indicating the intervention delayed onset in addition to lowering overall incidence. The 28-day all-cause mortality difference between the two groups was not, so the perfusion-targeted strategy did not extend its benefit to short-term survival in this trial. Effect

Resuscitation quality

The PPI-guided group also cleared lactate faster in the first 6 hours, with a mean clearance rate of 28.5% versus 21.8% in the control group (P =.001), and accumulated less excess fluid by 72 hours, a positive balance of roughly 1,250 mL versus 1,850 mL (P <.001). Those two secondary findings point in the same direction as the primary result: patients guided by peripheral perfusion were resuscitated with tighter fluid control and cleared markers of poor tissue oxygenation more quickly, a pattern consistent with the mechanism the trial was designed to test. Effect

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