In patients with acute circulatory failure, deciding whether to administer intravenous fluids is often a life-or-death decision. Too little fluid can leave organs underperfused, while too much can cause pulmonary edema and other complications. Now, a new study suggests that a simple, non-invasive measurement from a standard pulse oximeter—the plethysmographic perfusion index (PPI)—could help guide these critical choices, offering a low-cost alternative to advanced cardiac monitoring.

The prospective observational study, conducted at Avicenna University Hospital, Cadi Ayyad University (Marrakesh, Morocco), aimed to determine whether changes in PPI could predict fluid responsiveness in patients with acute circulatory failure—a common and dangerous condition in intensive care units.

The PPI measures the ratio of pulsatile to non-pulsatile blood flow detected by a pulse oximeter, providing indirect insight into cardiac output and peripheral perfusion. Because cancerous areas or conditions that affect circulation alter bioimpedance, clinicians have proposed that shifts in PPI after a fluid bolus might indicate whether a patient’s heart can respond effectively to more fluids.

In this study, fifty adult ICU patients experiencing acute circulatory failure were enrolled between February and September 2024. Each received a 500-mL intravenous fluid bolus. The team used transthoracic echocardiography—the gold standard—to determine fluid responsiveness, classifying patients as responders if their velocity–time integral (VTI) across the left ventricular outflow tract increased by 15% or more after the fluid challenge. PPI was simultaneously recorded before and after fluid administration, and the relative change (ΔPPI) was calculated.

The results, published in the Journal of Intensive Medicine, showed that 66% of patients were fluid responsive according to echocardiography. A 33% increase in PPI identified responders with 70% sensitivity and 82% specificity, corresponding to an area under the ROC curve of 0.78—indicating moderate diagnostic accuracy. About 30% of patients fell into a “gray zone” of inconclusive values between 0% and 88%, underscoring that ΔPPI should be interpreted alongside clinical signs and other measurements.

Directional analysis showed 70% agreement between ΔPPI and echocardiographic results, suggesting that PPI can effectively track real changes in stroke volume. Because PPI is generated automatically by standard pulse oximeters, it requires no additional hardware, cost, or technical expertise. This makes it especially valuable in resource-limited or emergency settings where echocardiography or invasive hemodynamic monitoring may not be available.

The authors emphasize that larger multicenter studies are needed to validate the findings and refine ΔPPI thresholds for clinical use. While PPI should not replace echocardiography, it may serve as a complementary tool in guiding fluid resuscitation decisions globally, particularly in hospitals with limited access to advanced diagnostic equipment.

“Our findings support the use of ΔPPI as a pragmatic adjunct for fluid management, especially in resource-limited and emergency settings where advanced monitoring is often unavailable,” said Dr. Younes Aissaoui, corresponding author of the study.

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