Balanced crystalloids versus 0.9% saline for fluid resuscitation in children with septic shock: an updated systematic review and meta-analysis of randomized controlled trials.

BACKGROUND

0.9% (normal) saline remains the most widely used bolus resuscitation fluid in paediatric septic shock, despite a supraphysiological chloride content that may impair renal perfusion and cause hyperchloraemic acidosis. Whether balanced crystalloids, which more closely approximate plasma, improve clinical outcomes in children remains uncertain.

METHODS

Following PRISMA 2020 guidelines, PubMed/MEDLINE, Scopus, ScienceDirect and Web of Science were searched upto July 2026 for randomized trials of balanced or buffered crystalloids versus 0.9% saline in children (< 18 years) with sepsis or septic shock. Random-effects meta-analyses used RevMan 5.4.

RESULTS

Six trials (10,308 children) were included. Balanced crystalloids did not reduce in-hospital or ICU mortality (3.7% vs. 3.9%; RR 0.95, 95% CI 0.75-1.21), at 30 days (RR 1.08, 0.71-1.65) or at 90 days (RR 1.10, 0.83-1.45). Acute kidney injury was not reduced (RR 0.76, 0.46-1.27), but renal replacement therapy was (RR 0.67, 0.48-0.92). Hyperchloraemia (RR 0.65, 0.61-0.70), 6-hour chloride rise (MD - 3.99 mEq/L, - 5.57 to - 2.42) and hypernatraemia (RR 0.59, 0.42-0.83) were reduced, whereas hyperlactataemia was more frequent (RR 1.17, 1.00-1.38). No other safety, organ-support or resource-use outcome differed.

CONCLUSION

Balanced crystalloids reliably reduce hyperchloraemia, chloride loading, and hypernatraemia and are associated with less renal replacement therapy but confer no advantage in mortality or length of stay; the evidence now excludes a clinically important mortality benefit. They remain a physiologically preferable and equally safe default where available, but fluid choice should not displace early recognition, timely antimicrobials and haemodynamic support.

PROSPERO REGISTRATION: CRD420261468983.