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Peer-reviewedCC BYJournal of Clinical Medicine Research

Balanced Crystalloids Versus Normal Saline for Fluid Resuscitation in Pediatric Septic Shock: An Updated Systematic Review and Meta-Analysis

  • Hussein Saeed Alshahrani1
  • Orjuwan Saeed Alruzquwi2
  • Najwa Abdumalik Amiri2
  • Khalid Nawaf Almutairi3
  • Meshari Abdulkarim Almutairi4
  • Leena Turki AldakhilAllah5
  • Shaima Abdulatif Jaber Alsalmi6
  • Fatima Mahmoud Alkandari7
  • Majed Sultan Alenezi8
  • Amal Saeed M. Alrayzah9
  • Mohammad Yaseen Jaha5
  • Sara Ghadeer M. Alghadeer10
3 more authors
  • Abdulaziz Baki Aljohani11
  • Abeer Bassam Alkehaimi12
  • Zainab Ahmed Alsoliabi13
13 affiliations
  1. 1Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
  2. 2Ibn Sina National College, Jeddah, Saudi Arabia
  3. 3College of Medicine, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia
  4. 4College of Medicine, Majmaah University, Majmaah, Saudi Arabia
  5. 5College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
  6. 6Department of Pediatrics, King Salman Specialist Hospital, Taif, Saudi Arabia
  7. 7Faculty of Medicine, Cairo University, Kasr Al Ainy Hospital, Cairo, Egypt
  8. 8Department of Pharmacy, Eastern Province Maternity and Children Hospital, Dammam, Saudi Arabia
  9. 9College of Medicine, King Khalid University, Abha, Saudi Arabia
  10. 10College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
  11. 11College of Nursing, Taibah University, Madinah, Saudi Arabia
  12. 12College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
  13. 13Department of Pharmacy, Qatif Central Hospital, Ministry of Health, Dammam, Saudi Arabia
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Abstract

Background: Crystalloid fluid is central to pediatric septic shock resuscitation, but the optimal composition is uncertain. Normal saline delivers a supraphysiologic chloride load that may promote hyperchloremic acidosis and renal injury, whereas balanced crystalloids approximate extracellular fluid. Pediatric evidence is mixed, and prior syntheses preceded the large PRoMPT BOLUS trial. We compared balanced crystalloids with normal saline for resuscitation in children with sepsis or septic shock.

Methods: We searched PubMed/MEDLINE, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to April 2026 for randomized controlled trials (RCTs) and observational cohorts comparing balanced crystalloids with 0.9% saline in children (≤ 18 years) with sepsis or septic shock requiring fluid resuscitation. Co-primary outcomes were all-cause mortality and acute kidney injury (AKI). Data were pooled using random-effects models (risk ratios (RR), mean differences (MD); 95% confidence interval (CI)), with trial sequential analysis (TSA) for primary outcomes. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and was registered in PROSPERO.

Results: Nine studies (five RCTs, four observational cohorts) were included. Balanced crystalloids did not reduce mortality (RR, 0.94; 95% CI, 0.83–1.06; I2 = 0%) or AKI (RR, 0.84; 95% CI, 0.61–1.16; I2 = 73.5%); TSA showed the required information size was unmet, leaving both inconclusive. Balanced crystalloids significantly reduced renal replacement therapy (RR 0.74; 95% CI, 0.56–0.96; I2 = 23.5%) and hyperchloremia (RR, 0.65; 95% CI, 0.61–0.69; I2 = 0%). No differences emerged for major adverse kidney events within 30 days (MAKE30) (RR, 1.11; 95% CI, 0.87–1.41), mechanical ventilation (RR, 0.97, 95% CI, 0.85–1.11), or hospital (MD, 1.49 days) and pediatric intensive care unit (PICU) (MD, 0.84 days) length of stay.

Conclusions: In pediatric sepsis or septic shock, balanced crystalloids consistently reduce hyperchloremia and the need for renal replacement therapy but do not significantly reduce mortality, AKI, MAKE30, mechanical ventilation, or length of stay. Incorporating recent pragmatic randomized data supports cautious interpretation, and TSA confirms that the primary-outcome evidence remains inconclusive. Adequately powered, phenotype-informed trials are needed.

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Cite

BibTeXRIS
BibTeX
@article{alshahrani2026balanced,
  title = {{Balanced Crystalloids Versus Normal Saline for Fluid Resuscitation in Pediatric Septic Shock: An Updated Systematic Review and Meta-Analysis}},
  author = {Hussein Saeed Alshahrani and Orjuwan Saeed Alruzquwi and Najwa Abdumalik Amiri and Khalid Nawaf Almutairi and Meshari Abdulkarim Almutairi and Leena Turki AldakhilAllah and Shaima Abdulatif Jaber Alsalmi and Fatima Mahmoud Alkandari and Majed Sultan Alenezi and Amal Saeed M. Alrayzah and Mohammad Yaseen Jaha and Sara Ghadeer M. Alghadeer and Abdulaziz Baki Aljohani and Abeer Bassam Alkehaimi and Zainab Ahmed Alsoliabi},
  journal = {Journal of Clinical Medicine Research},
  year = {2026},
  month = oct,
  doi = {10.14740/jocmr6685},
  url = {https://europepmc.org/article/PMC/PMC13719638},
  note = {CC BY},
}
RIS
TY  - JOUR
TI  - Balanced Crystalloids Versus Normal Saline for Fluid Resuscitation in Pediatric Septic Shock: An Updated Systematic Review and Meta-Analysis
AU  - Hussein Saeed Alshahrani
AU  - Orjuwan Saeed Alruzquwi
AU  - Najwa Abdumalik Amiri
AU  - Khalid Nawaf Almutairi
AU  - Meshari Abdulkarim Almutairi
AU  - Leena Turki AldakhilAllah
AU  - Shaima Abdulatif Jaber Alsalmi
AU  - Fatima Mahmoud Alkandari
AU  - Majed Sultan Alenezi
AU  - Amal Saeed M. Alrayzah
AU  - Mohammad Yaseen Jaha
AU  - Sara Ghadeer M. Alghadeer
AU  - Abdulaziz Baki Aljohani
AU  - Abeer Bassam Alkehaimi
AU  - Zainab Ahmed Alsoliabi
PY  - 2026
DA  - 2026/10/01
JO  - Journal of Clinical Medicine Research
DO  - 10.14740/jocmr6685
UR  - https://europepmc.org/article/PMC/PMC13719638
AB  - Background: Crystalloid fluid is central to pediatric septic shock resuscitation, but the optimal composition is uncertain. Normal saline delivers a supraphysiologic chloride load that may promote hyperchloremic acidosis and renal injury, whereas balanced crystalloids approximate extracellular fluid. Pediatric evidence is mixed, and prior syntheses preceded the large PRoMPT BOLUS trial. We compared balanced crystalloids with normal saline for resuscitation in children with sepsis or septic shock.  Methods: We searched PubMed/MEDLINE, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to April 2026 for randomized controlled trials (RCTs) and observational cohorts comparing balanced crystalloids with 0.9% saline in children (≤ 18 years) with sepsis or septic shock requiring fluid resuscitation. Co-primary outcomes were all-cause mortality and acute kidney injury (AKI). Data were pooled using random-effects models (risk ratios (RR), mean differences (MD); 95% confidence interval (CI)), with trial sequential analysis (TSA) for primary outcomes. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and was registered in PROSPERO.  Results: Nine studies (five RCTs, four observational cohorts) were included. Balanced crystalloids did not reduce mortality (RR, 0.94; 95% CI, 0.83–1.06; I2 = 0%) or AKI (RR, 0.84; 95% CI, 0.61–1.16; I2 = 73.5%); TSA showed the required information size was unmet, leaving both inconclusive. Balanced crystalloids significantly reduced renal replacement therapy (RR 0.74; 95% CI, 0.56–0.96; I2 = 23.5%) and hyperchloremia (RR, 0.65; 95% CI, 0.61–0.69; I2 = 0%). No differences emerged for major adverse kidney events within 30 days (MAKE30) (RR, 1.11; 95% CI, 0.87–1.41), mechanical ventilation (RR, 0.97, 95% CI, 0.85–1.11), or hospital (MD, 1.49 days) and pediatric intensive care unit (PICU) (MD, 0.84 days) length of stay.  Conclusions: In pediatric sepsis or septic shock, balanced crystalloids consistently reduce hyperchloremia and the need for renal replacement therapy but do not significantly reduce mortality, AKI, MAKE30, mechanical ventilation, or length of stay. Incorporating recent pragmatic randomized data supports cautious interpretation, and TSA confirms that the primary-outcome evidence remains inconclusive. Adequately powered, phenotype-informed trials are needed.
SN  - 1918-3003
SN  - 1918-3011
ER  -