🩺 THIS WEEK IN EM
PRoMPT BOLUS: The Pediatric Sepsis Fluid Debate Gets a Real Answer
For years the pediatric sepsis fluid argument has been driven by physiology, extrapolation, and a little ideology. Balanced fluids should reduce hyperchloremia, maybe protect the kidneys, and maybe outperform saline in the sickest children. The problem was that the direct evidence was thinner than the certainty of the opinions.
PRoMPT BOLUS finally gave this question the trial it deserved. Investigators enrolled more than 9,000 children 2 months to younger than 18 years of age with suspected septic shock across 47 emergency departments in five countries and randomized them to balanced crystalloids or 0.9% saline for resuscitation and maintenance fluids for up to 48 hours. The primary outcome was a major adverse kidney event within 30 days.
The result was not subtle: balanced fluid did not beat saline on the primary outcome. In other words, the biochemistry argument did not translate into a patient-centered win.
That matters in the ED because this is exactly the kind of question that can burn time and confidence at the bedside. If a child with septic shock needs fluid now, the right move is still to recognize shock early, get the bolus running, reassess perfusion, and escalate appropriately. PRoMPT BOLUS does not say fluid choice is irrelevant forever. It says the case for balanced fluid superiority in pediatric septic shock is not there.
Bottom line: In the large PRoMPT BOLUS trial, balanced crystalloids did not improve major kidney outcomes or recovery compared with 0.9% saline in children treated for septic shock. For pediatric sepsis resuscitation, either fluid is reasonable; speed and reassessment matter more than chasing a theoretical fluid advantage.
Balamuth F, Weiss SL, Long E, et al. Balanced Fluid or 0.9% Saline in Children Treated for Septic Shock. N Engl J Med. 2026.
EVERDAC: Not Every Shock Patient Needs an Arterial Line Right Now
Arterial lines have been treated as part of the shock uniform for so long that many clinicians barely experience the decision as a decision. Pressors on? Put the line in. But arterial catheters are not benign. They hurt, they bleed, and they consume time, and they can make a low-dose-pressor patient look “more ICU” without clearly making that patient safer.
The EVERDAC trial tested that reflex directly. In this multicenter noninferiority trial, 1,010 critically ill adults with shock were randomized to a noninvasive-first strategy or routine early arterial catheterization. The mortality result went the wrong way for the dogma: death by day 28 occurred in 34.3% of the noninvasive-strategy group and 36.9% of the invasive-strategy group, meeting noninferiority. The exposure difference was huge: only 14.7% of the noninvasive group ultimately received an arterial catheter, versus 98.2% of the routine-invasive group.
This is not a paper about never placing arterial lines. It is a paper about being selective. There are still patients where beat-to-beat monitoring, frequent blood gases, severe vasopressor needs, unreliable cuff pressures, or major hemodynamic instability make an arterial line the right call. What EVERDAC challenges is the idea that the line needs to go in early just because the word “shock” is on the chart.
For the ED, the practical implication is useful. If your patient is on modest vasopressor support with a reliable cuff pressure and you are trying to prioritize source control, airway management, transfer, or broader resuscitation steps, you do not need to pretend the arterial line is always the first domino.
Bottom line: EVERDAC showed that a noninvasive-first monitoring strategy was noninferior to routine early arterial catheterization for 28-day mortality in critically ill patients with shock. Arterial lines still matter for selected patients, but the reflex “shock equals immediate A-line” is weaker than many of us were taught.
Muller G, Contou D, Ehrmann S, et al; EVERDAC Trial Group. Deferring Arterial Catheterization in Critically Ill Patients with Shock. N Engl J Med. 2025;393(19):1875-1888.
APPAC at 10 Years: Antibiotics-First Appendicitis Is Real, but It Is Not a Free Lunch
The ED conversation around uncomplicated appendicitis has changed a lot in the last decade. “You need surgery” is no longer the only evidence-based sentence available. But the harder question has always been the long one: if you treat with antibiotics first, what happens years later?
The 10-year follow-up of the APPAC randomized trial gives the clearest long view yet. In the original trial, 530 adults 18 to 60 years of age with CT-confirmed uncomplicated appendicitis were randomized to appendectomy or antibiotics. At 10 years, patients initially assigned to antibiotics had a true appendicitis recurrence rate of 37.8% and a cumulative appendectomy rate of 44.3%. So yes, many patients eventually returned to the OR.
But the story does not end there. The overall cumulative complication rate over 10 years was substantially lower in the antibiotics group than in the appendectomy group, and quality of life did not significantly differ between the two strategies. That is the part clinicians often understate when they summarize this literature as “antibiotics work until they fail.” The more accurate version is that antibiotics-first is a legitimate management pathway with a real tradeoff: fewer cumulative complications over time in exchange for a meaningful long-term recurrence and surgery risk.
That tradeoff is exactly what makes this an ED paper. When you diagnose uncomplicated appendicitis in an adult and the surgical team is open to nonoperative management, your job is no longer just to tee up the consent for the OR. It is to frame the choice honestly. Some patients will value avoiding surgery now even if recurrence remains on the table. Others will hear a near-44% eventual appendectomy rate and choose definitive surgery immediately. Both are reasonable.
Bottom line: The APPAC 10-year follow-up supports antibiotics-first treatment as a real option for CT-confirmed uncomplicated appendicitis in adults, but not a magic exit from surgery. Many patients avoid appendectomy long term, but recurrence and later surgery remain common enough that shared decision-making matters.
Salminen P, Salminen R, Kallio J, et al. Antibiotic Therapy for Uncomplicated Acute Appendicitis: Ten-Year Follow-Up of the APPAC Randomized Clinical Trial. JAMA. 2026;335(12):1041-1049.
🔭 Next Week
Older adults and ground-level falls: Which findings actually predict traumatic intracranial hemorrhage, and which ones we overweight
Trigger point injections for low back pain: Do they meaningfully outperform standard ED therapy, or just feel satisfying
Presyncope vs syncope: Are we underestimating the short-term cardiac risk of presyncope in the ED?
The Hallway Consult is built for EM clinicians who want the useful version of the literature. Forward it to a colleague if it helped.
— The Hallway Consult team