FLUID RESUSCITATION IN SEPSIS: BALANCED CRYSTALLOIDS VERSUS SALINE
Keywords:
sepsis; septic shock; balanced crystalloids; saline; lactated Ringer's; Plasma-Lyte; acute kidney injury; fluid resuscitationAbstract
DOI: https://doi.org/10.46296/yc.v10i19.0984
Abstract
Introduction: Crystalloid resuscitation is an essential intervention in sepsis; however, the high chloride concentration of 0.9% saline can promote hyperchloremia, metabolic acidosis, and alterations in renal perfusion. Balanced crystalloids contain chloride concentrations closer to physiological levels and include organic buffers; thus, they may reduce renal events and mortality. Objective: To compare the efficacy and safety of balanced crystalloids versus 0.9% saline for the resuscitation of adults with sepsis or septic shock. Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines. Searches were performed in PubMed/MEDLINE, SciELO, and Google Scholar up to August 10, 2026. Comparative studies involving adults with sepsis that evaluated balanced crystalloids (Lactated Ringer’s, Ringer’s acetate, or Plasma-Lyte) versus 0.9% saline were included. The primary outcome was mortality; secondary outcomes included acute kidney injury (AKI), renal replacement therapy (RRT), hyperchloremia, and organ support-free days. Randomized evidence was prioritized; risk of bias was assessed using Cochrane RoB 2 criteria, and certainty of evidence was evaluated using the GRADE approach. Results: Eight independent studies involving 8,173 patients with sepsis were included; seven provided direct randomized comparisons regarding mortality. Synthesis of these RCTs showed lower mortality with balanced crystalloids (31.7% vs. 34.8%; RR 0.92; 95% CI 0.86–0.98; I²=37%). In four RCTs, the incidence of AKI was lower with balanced crystalloids (34.3% vs. 39.1%; RR 0.86; 95% CI 0.78–0.96; I²=0%). Hyperchloremia was also less frequent (RR 0.68; 95% CI 0.52–0.90), and the need for RRT showed a borderline reduction (RR 0.74; 95% CI 0.56–1.00). The results were consistent with the secondary analysis of the CLOVERS trial, although the latter does not constitute a randomized comparison by crystalloid type. Conclusion: In adults with sepsis, balanced crystalloids likely offer a small clinical advantage over 0.9% saline—particularly regarding mortality and AKI—with a clear biochemical benefit concerning chloride load. The certainty of evidence is moderate for mortality and AKI, and lower for other outcomes. The choice should be individualized, especially in situations involving a risk of intracranial hypertension or other circumstances where fluid composition is critical.
Keywords: sepsis; septic shock; balanced crystalloids; saline; lactated Ringer's; Plasma-Lyte; acute kidney injury; fluid resuscitation.
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