Is Saline or Balanced Fluid Better for Pediatric Shock?

Balanced fluid pediatric shock resuscitation remains a subject of intense debate among emergency physicians worldwide. For many years, doctors wondered if balanced crystalloids outperformed 0.9% saline. Consequently, researchers launched a massive pragmatic trial to find answers. Specifically, the study included over 9,000 children across 47 emergency departments. Therefore, the results provide clear guidance for pediatricians everywhere, including in India.

Evidence for Balanced Fluid Pediatric Shock

The PRONTO trial compared hospital mortality and kidney dysfunction between the two fluids. Furthermore, the findings showed no significant difference in primary outcomes. Therefore, clinicians can now choose either fluid confidently during initial resuscitation. Interestingly, saline caused higher blood chloride levels in some participants. However, these biochemical changes did not affect clinical recovery. Additionally, balanced fluids led to slightly higher lactate levels. Nevertheless, the trial confirms that either strategy is safe and effective.

Clinical Implications for Pediatricians

Doctors should prioritize fluid availability when treating septic shock in children. Therefore, the findings simplify emergency protocols for many resource-limited hospitals. Pediatricians in India often utilize normal saline due to its lower cost. Consequently, this study offers reassurance regarding its continued use. Furthermore, the trial answers a long-standing clinical question definitively. Consequently, healthcare providers can focus on other critical aspects of sepsis care.

Frequently Asked Questions

Q1: Did the trial find a superior fluid for pediatric shock?

No, the PRONTO trial found no significant difference in mortality or organ dysfunction between balanced fluids and saline.

Q2: What were the main biochemical differences observed?

Saline led to higher blood chloride levels, while balanced fluids resulted in slightly higher lactate levels.

References

1. Balamuth F et al. Balanced Fluid or 0.9% Saline in Children Treated for Septic Shock. N Engl J Med. 2026 Apr 24. doi: 10.1056/NEJMoa2601969. PMID: 42028918.
2. Weiss SL, et al. Crystalloid Fluid Choice and Clinical Outcomes in Pediatric Sepsis. JAMA Pediatr. 2017;171(12):e173341.
3. Evans L, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021;49(11):e1063-e1143.