Journal Club E62: The Fluid Wars: Balanced Crystalloids vs Saline, and the WATERFALL Reset

Saline is not physiologic, but the outcome differences are small and context-dependent. SALT-ED and SMART favor balanced crystalloids by about one percentage point on kidney events, BaSICS and PLUS are neutral for mortality, the BEST-Living pooled analysis suggests probable rather than proven benefit with possible harm in traumatic brain injury, and WATERFALL shows that in pancreatitis the strategy matters more than the bag. A 2025 meta-analysis of five small trials supports lactated Ringer's over saline in acute pancreatitis, and the WATERLAND trial is the ongoing head-to-head that should answer the fluid question directly.