We have known that resuscitation with balanced crystalloids was associated with better outcomes, than normal saline.  However, I have believed that in the early phase of resuscitation, volume of any crystalloids is still better than little volume. Thus, a couple of liters of normal saline (0.9% saline) would not hurt. However, the recent secondary analysis from the Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis (CLOVERS) trial might have changed my practice.
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Settings:

60 ICU in the United States between 2018 to 2022. This is the secondary analysis of the Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis (CLOVERS) trial population
Participants: Patients with sepsis-induced hypotension after receiving fluid resuscitation (from 1-3 litters). Participants who received lactate ringers (622 patients) were compared with patients who received normal saline (690 patients).
Outcome measurement:
Death before discharge home by day 90.
Hospital-free days at 28 days
Study Results:
Dead occurred in 12.2% of LR group (76/622) vs. 15.9% (110/690) patients of the NS group, Adjusted Hazard Ratio 0.71 (95% CI 0.51-0.99, p=0.043)
Patients receiving LR had more hospital-free days at 28 days than those receiving 0.9% saline (16.6 ± 10.8 vs. 15.4 ± 11.4 d, respectively). The mean difference was 1.6 days (95% CI, 0.4–2.8; p = 0.009).
Discussion:
This study confirms that not only early resuscitation is important, but the fluid choice during the early resuscitation phase is also important, especially in patients with signs and symptoms of sepsis.

Thus, even during pre-hospital phase and in the ED, clinicians should consider to use LR or other balanced solutions if available.
Conclusion:
Among patients with sepsis-induced hypotension, resuscitation with Lactate Ringer was associated with better outcomes than normal saline.

References

Gelbenegger G, Shapiro NI, Zeitlinger M, Jilma B, Douglas IS, Jorda A. Lactated Ringer's or Normal Saline for Initial Fluid Resuscitation in Sepsis-Induced Hypotension. Crit Care Med. 2025 May 1;53(5):e1140-e1144. doi: 10.1097/CCM.0000000000006601. Epub 2025 Feb 19. PMID: 39969246; PMCID: PMC12047640.