Why I Stopped Using Normal Saline | SALT-ED [Journal Club]

Welcome to Overheard Journal Club — a new series within Overheard in the Emergency Room where I take a single paper that has changed my practice, walk you through it PICO-style, and tell you exactly what to do with it on your next shift. In this inaugural episode, I'm breaking down my favourite Emergency Medicine paper of all time: the SALT-ED trial. Self and colleagues, NEJM 2018, 13,347 noncritically ill adults randomised by calendar month to either balanced crystalloids or normal saline. The result reshaped how I think about one of the most common interventions in all of medicine — the humble IV fluid bolus. In this episode you will learn: • Why "normal" saline is actually pretty abnormal — the supraphysiologic chloride load explained in plain language. • How the SALT-ED pragmatic crossover design got 88% adherence without blinding. • What the primary and secondary outcomes actually showed — including the MAKE30 composite that drives the practice change. • Where the trial is genuinely vulnerable to critique, and where I think the most common criticisms fall short. • My current default rule for IV fluid choice in the ED, the short list of hard indications for saline, and the ceftriaxone-LR compatibility workaround that doesn't require giving up best-evidence fluids. Key resources • SALT-ED trial (NEJM 2018): https://doi.org/10.1056/NEJMoa1711586 • SMART trial — ICU companion (NEJM 2018): https://doi.org/10.1056/NEJMoa1711584 • Companion blog post + full references: https://drcois.com/blog • The Bottom Line summary: https://www.thebottomline.org.uk/summ... Key papers cited • Self WH et al. NEJM 2018;378(9):819-828. • Semler MW et al. NEJM 2018;378(9):829-839. • Yunos NM et al. JAMA 2012;308(15):1566-1572. • Myburgh JA, Mythen MG. NEJM 2013;369:1243-1251. Disclosures No financial conflicts of interest relevant to this episode. Views are my own and do not represent any employer or institution. Disclaimer This content is for educational purposes only and does not constitute medical advice. It does not establish a physician-patient relationship. Always discuss management decisions with a qualified clinician.