• Balamuth F, Weiss SL, Long E, et al. N Engl J Med 2026;395:870-881. Balanced fluid or 0.9% saline in children treated for septic shock. 

Key finding: No significant difference was seen in the incidence of death, new renal-replacement therapy, or persistent kidney dysfunction when fluid resuscitation was administered with balanced fluid as compared with 0.9% saline.

• MF O’Connor, J Bubeck-Wardenburg. N Engl J Med 2026;395:921-922. Commentary: Fluid Resuscitation in Patients with Sepsis — For Whom the Balance Tolls
  

From the commentary:

“Balamuth and colleagues report the findings of the Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis (PRoMPT BOLUS), a large, international, pediatric trial evaluating whether treatment with balanced crystalloid fluid (lactated Ringer’s solution, Plasma-Lyte, or Hartmann’s solution according to clinician discretion) is associated with better kidney-function outcomes than therapy with normal saline in patients with sepsis..

Evaluating more than 8000 children who were well matched with respect to the severity of sepsis at initial presentation, the current trial showed that the nature of fluid administered did not significantly affect patient outcomes…This finding contrasts with those of SMART and the SALT-ED trial as well as those of two other trials…^6,7 

As appropriately recognized by Balamuth et al., less-severe illness in the participants in the present trial may have limited the ability of the trial to detect an influence of fluid composition on clinical outcome. Taken together, both adult and pediatric studies suggest that the clinical benefit of balanced-fluid administration correlates directly with the degree of cellular homeostatic disruption in patients with sepsis…

It is important to consider that harm has not been associated with the administration of balanced fluids in any clinical study. With the notable exception of patients with intracranial hypertension, the prudent approach may be to use balanced fluids as standard care in patients with sepsis.”

My take: For most children with sepsis, the outcomes are likely to be similar between those receiving balanced fluids and saline. However, sicker patients, which may be difficult to discern initially, may benefit from balanced fluids.

Related blog posts:

• Is Lactated Ringer’s Better Than Normal Saline For Routine Use?
• Choosing the Right IV Fluids Risk of hypokalemia with isotonic fluids with low potassium content
• AAP Recommends Isotonic Maintenance IV Fluids
• Optimizing Fluid Resuscitation in Pediatric Acute Pancreatitis
• More Data Supporting Lactated Ringers for Acute Pancreatitis

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