Does the type of crystalloid we choose change outcomes for children with septic shock? Dr. Bob Belfer speaks with pediatric intensivist and sepsis researcher Dr. Scott Weiss about the landmark PRoMPT BOLUS trial, which compared balanced crystalloids with 0.9% saline in more than 9,000 children. They discuss why fluid boluses help - and why their effects may be temporary - the meaning of the MAKE30 outcome, how the trial’s findings should influence fluid choice in the ED and ICU, and why lower rates of hyperchloremia did not translate into better patient-centered outcomes. They also review the 2026 pediatric Surviving Sepsis guidelines, including sepsis screening, the timing and selection of vasoactive medications, lactate and procalcitonin, point-of-care ultrasound, and the emerging role of AI and precision medicine in pediatric sepsis. Studies discussedBalamuth F, Weiss SL, Long E, et al. Balanced fluid or 0.9% saline in children treated for septic shock. N Engl J Med. Published online April 24, 2026. Weiss SL, Balamuth F, Long E, et al. PRagMatic Pediatric Trial of Balanced vs nOrmaL Saline FlUid in Sepsis: study protocol for the PRoMPT BOLUS randomized interventional trial. Trials. 2021;22(1):776. Weiss SL, Keele L, Balamuth F, et al. Crystalloid fluid choice and clinical outcomes in pediatric sepsis: a matched retrospective cohort study. J Pediatr. 2017;182:304-310.e10. Lehr AR, Rached-d’Astous S, Barrowman N, et al. Balanced versus unbalanced fluid in critically ill children: systematic review and meta-analysis. Pediatr Crit Care Med. 2022;23(3):181-191. Self WH, Semler MW, Wanderer JP, et al. Balanced crystalloids versus saline in noncritically ill adults. N Engl J Med. 2018;378(9):819-828. Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378(9):829-839. Zampieri FG, Machado FR, Biondi RS, et al. Effect of intravenous fluid treatment with a balanced solution vs 0.9% saline solution on mortality in critically ill patients: the BaSICS randomized clinical trial. JAMA. 2021;326(9):818-829. Finfer S, Micallef S, Hammond N, et al. Balanced multielectrolyte solution versus saline in critically ill adults. N Engl J Med. 2022;386(9):815-826. Delgado Moya FP, Antequera A, Muriel A, et al. Buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children. Cochrane Database Syst Rev. 2026;4(4). Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign international guidelines for the management of sepsis and septic shock in children 2026. Intensive Care Med. 2026;52(5):937-983. Weiss SL, Peters MJ, Alhazzani W, et al. Executive summary: Surviving Sepsis Campaign international guidelines for the management of sepsis and septic shock in children 2026. Pediatr Crit Care Med. 2026;27(4):494-513. Scott HF, Sevick CJ, Colborn KL, et al. Clinical Decision Support for Septic Shock in the Emergency Department: A Cluster Randomized Trial. Pediatrics. 2025;156(1):e2024069478. Ventura AMC, Shieh HH, Bousso A, et al. Double-blind prospective randomized controlled trial of dopamine versus epinephrine as first-line vasoactive drugs in pediatric septic shock. Crit Care Med. 2015;43(11):2292-2302. Ramaswamy KN, Singhi S, Jayashree M, Bansal A, Nallasamy K. Double-blind randomized clinical trial comparing dopamine and epinephrine in pediatric fluid-refractory hypotensive septic shock. Pediatr Crit Care Med. 2016;17(11). Eisenberg MA, Carlson L, Graham DA, et al. Epinephrine vs norepinephrine as initial treatment in children with septic shock. JAMA Netw Open. 2025;8(4). About the guestDr. Scott Weiss is the Division Chief of Critical Care Medicine at Nemours Children’s Hospital. His clinical and translational research focuses on pediatric sepsis, including mitochondrial dysfunction, fluid resuscitation, biomarkers, and precision medicine. About the podcastThe PEM Podcast features thoughtful conversations, practical teaching, and the people and ideas shaping pediatric emergency medicine. It is hosted by Dr. Bob Belfer and is part of HipPEMcrates, an independent pediatric emergency medicine education platform. Visit HipPEMcrates.com for pediatric emergency medicine articles, literature reviews, clinical pearls, and educational resources.
