\nA large NIH-supported study of more than 8,000 children with suspected septic shock showed no difference in kidney complications whether they received balanced fluids or saline for resuscitation.<\/figcaption><\/figure>\n\u201cSaline has the advantage of a long record \u2014 150 years of use,\u201d Scott L. Weiss, MD, MSCE, FCCM, <\/b>chief of critical care medicine and vice chair of research in the department of pediatrics at Nemours Children\u2019s Hospital, told Healio in an interview. \u201cIt\u2019s inexpensive, it\u2019s compatible with pretty much all other medications, which makes it a practical choice when you are giving multiple things to a patient in short periods of time through similar IVs, and it is isotonic to the blood, so you don\u2019t have to worry about concerns about swelling of the brain.\u201d<\/p>\n
However, Weiss said there are concerns that high volumes of saline could increase chloride levels in the blood and lead to kidney complications in children. Two studies from Vanderbilt University Medical Center showed that using balanced fluid instead of saline could reduce complications, although Weiss said those results have not been replicated since.<\/p>\n
Some physicians have switched to using balanced fluid to resuscitate children with septic shock, but when Weiss and colleagues surveyed emergency physicians, they found that the vast majority still use saline. <\/p>\n
\u201cThe story changes a little bit when you move patients to the ICU,\u201d Frances Balamuth, MD, PhD, MSCE, <\/b>professor of pediatrics at Perelman School of Medicine at the University of Pennsylvania, told Healio. \u201cIn our survey of ICU folks, it was a much more balanced answer.\u201d<\/p>\n
Balamuth, Weiss and colleagues developed the PRoMPT BOLUS trial to study if switching to balanced fluid at a large scale would reduce kidney complications. They conducted the pragmatic clinical trial at 47 EDs in Australia, Canada, Costa Rica, New Zealand and the United States from Aug. 26, 2020, through Oct. 31, 2025. It included 8,482 children aged 2 months through 17 years (50.8% boys; median age, 6.8 years) who presented to the ED with suspected septic shock. <\/p>\n
The researchers assigned 4,235 children to receive balanced fluid and 4,247 children to receive 0.9% saline. Each child needed to receive at least two boluses of fluid to be included. The primary outcome was a major adverse kidney event \u2014 including renal replacement therapy, persistent kidney dysfunction and death \u2014 within 30 days of treatment.<\/p>\n
Balamuth said the researchers hypothesized that use of balanced fluid would result in fewer kidney complications compared with saline. The results showed no difference.<\/p>\n
According to the authors, major adverse kidney events occurred in 3.4% of children who received balanced fluid and 3% of children who received saline (risk ratio = 1.1; 95% CI, 0.88-1.4). The researchers also found no difference in secondary outcomes, including length of hospitalization, hospital-free days following treatment, death before discharge or death within 90 days of treatment.<\/p>\n
When looking at safety outcomes, the authors found that children who received balanced fluid were less likely to develop hypernatremia and hyperchloremia than children who received saline, and they were more likely to develop hyperlactatemia.<\/p>\n
\u201cI think we were reassured \u2014 or gained confidence \u2014 by the fact that we saw all of the biochemical differences that were expected,\u201d Balamuth said. \u201cBut those didn\u2019t translate to clinical changes.\u201d<\/p>\n
Weiss said this work is ongoing. The researchers collected blood and urine samples at three sites to see if there are any subtle differences in kidney injury biomarkers. They are also conducting two ancillary studies \u2014 one that is using electronic health record data to track long-term outcomes and another investigating endothelial and glycocalyx biomarkers to better understand the mechanistic effects of each fluid.<\/p>\n
\u201cOur findings are very clear that any fluid you have on hand is safe and effective to use, and most kids will do great with that,\u201d Balamuth said.<\/p>\n
For more information:<\/h2>\n Frances Balamuth, MD, PhD, MSCE, <\/b>can be reached at balamuthf@chop.edu.<\/p>\n
Scott Weiss, MD, MSCE, FCCM, <\/b>can be reached at scott.weiss@nemours.org.<\/p>\n\n
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Sources\/Disclosures<\/h3>\n Source: <\/h2>\n \nBalamuth F, et al. New Engl J Med. <\/i>2026; doi:10.1056\/NEJMoa2601969.\n<\/p>\nReferences:<\/h2>\n\nBalamuth F. Release of the PRoMPT BOLUS Results. Presented at: Pediatric Academic Societies annual meeting; April 24-27, 2026; Boston.<\/li>\n Weiss SL. Controversies in the choice of fluid for septic shock. Presented at: Pediatric Academic Societies annual meeting; April 24-27, 2026; Boston.<\/li>\n<\/ul>\n\n
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