Effect of goal-directed fluid resuscitation therapy based on peripheral perfusion index on acute skin failure in elderly critically ill patients: A randomized controlled trial

BACKGROUND: This study aimed to evaluate the effect of the peripheral perfusion index (PPI)-based goal-directed fluid resuscitation strategy for reducing the incidence of acute skin failure (ASF) in elderly critically ill patients. METHODS: We conducted a prospective, randomized, parallel-controlled study by enrolling 216 elderly critically ill patients who required early active fluid resuscitation from January 2025 to December 2025. They were randomly assigned to 2 categories: PPI-guided and conventional resuscitation groups. The intervention group considered PPI ≥1.4 as an additional resuscitation endpoint with conventional macrohemodynamic goals. Based on routine indicators, the control group received fluid management only. Our primary outcome comprised the incidence of ASF within 7 days of intensive care unit admission. Secondary outcomes included time to ASF onset, resuscitation quality indicators, organ function, and long-term prognosis. Data were analyzed according to the intention-to-treat principle. RESULTS: Our study involved 204 patients (103 intervention and 101 control). The intervention group (14.6%, 15/103) experienced a significantly reduced 7-day incidence of ASF compared with the control group (29.7%, 30/101, P = .009). However, the median time to ASF onset was prolonged in the intervention group (5.2 days vs 3.1 days, log-rank P = .012). Regarding the resuscitation quality, the intervention group demonstrated a higher 6-hour lactate clearance rate (28.5% ± 12.3% vs 21.8% ± 14.1%, P = .001) and reduced cumulative positive fluid balance at 72 hours (+1250 ± 980 mL vs +1850 ± 1100 mL, P < .001). The 28-day all-cause mortality between the groups remained nonsignificant. CONCLUSION: A PPI-based goal-directed fluid resuscitation strategy significantly reduces the risk of ASF in elderly critically ill patients, improves early perfusion marker assessments, and optimizes fluid management. This noninvasive, bedside monitoring approach provides a new clinical rationale for protecting skin health in critically ill patients.