Choice of crystalloids in sepsis: a conundrum waiting to be solved

One of the mainstays of sepsis and septic shock management is early intravenous fluid resuscitation to correct intravascular hypovolemia and restore adequate perfusion (1). There is an ongoing controversy on the optimal volume and choice of intravenous fluids to be administered (2,3). Recent systematic reviews and meta-analyses have concluded that pentastarch and hydroxyethyl starch are inferior to crystalloids as starch solutions increase the risk of kidney injury and death in patients with sepsis (4,5). Non-synthetic colloids such as albumin demonstrated no additional measurable harm or benefit when compared to crystalloids in sepsis (6,7). While the debate on crystalloids vs. non-synthetic colloids continues, another deliberation regarding the choice of crystalloids; ‘balanced’ vs. ‘non-balanced’, has started to garner interest.