Should I give Ringer's lactate (RL) or normal saline (NS) to a patient with hypertension?

Fluid Choice in Hypertensive Patients

In a patient with elevated blood pressure requiring intravenous fluids, use balanced crystalloids such as Ringer's lactate (RL) as first-line therapy, with cautious volume administration to avoid exacerbating hypertension. 1

Preferred Fluid Selection

• Balanced crystalloids like Ringer's lactate are recommended over normal saline (NS) for most hospitalized patients requiring fluid therapy. 1
• The evidence shows balanced crystalloids may reduce acute kidney injury and potentially decrease mortality compared to normal saline. 1
• Normal saline should be limited, especially in patients with existing electrolyte derangements, acidosis, or hyperchloremia. 1

Why Ringer's Lactate is Preferred

• RL contains near-physiological concentrations of electrolytes and has lower chloride content than NS, reducing the risk of hyperchloremic metabolic acidosis. 2
• Normal saline contains 154 mmol/L of both sodium and chloride, making it hyperchloremic compared to plasma, which can worsen acidosis and electrolyte derangements. 1, 2
• The SMART trial (15,802 ICU patients) demonstrated that balanced crystalloids resulted in lower rates of major adverse kidney events compared to saline (14.3% vs 15.4%). 1

Volume Administration Strategy in Hypertension

• Administer fluids cautiously with careful hemodynamic monitoring to prevent volume overload, which can worsen hypertension and lead to organ dysfunction. 1, 2
• Patients with hypertension often have underlying cardiovascular disease and are at higher risk for volume overload complications including pulmonary edema and worsening heart failure. 2
• If the patient has low central venous pressure (assessed by IVC ultrasound showing small/collapsible IVC), modest fluid challenge (≤500 mL) may be appropriate. 1
• Avoid aggressive volume loading if signs of elevated central venous pressure are present, as this can over-distend the heart and reduce cardiac output. 1

Specific Clinical Scenarios

If Hypotension Coexists with Hypertensive History:

• Use balanced crystalloids for initial resuscitation, targeting restoration of end-organ perfusion. 1
• Consider vasopressors (norepinephrine) if severe hypotension persists despite fluid administration, rather than excessive volume loading. 1

If No Hemodynamic Instability:

• Minimize unnecessary fluid administration in hypertensive patients. 1
• When fluids are indicated, use balanced crystalloids in the smallest effective volume. 1

Important Caveats

• Monitor for volume overload carefully in patients with heart failure or chronic kidney disease during any fluid resuscitation. 2
• Assess volume status and tissue perfusion within 6 hours if clinical response is inadequate. 2
• If large volumes are required (>1-1.5 L), balanced crystalloids are strongly preferred over normal saline to avoid hyperchloremic acidosis and coagulopathy. 1

What to Avoid

• Do not use normal saline as the primary resuscitation fluid if significant volumes are anticipated, as it causes hyperchloremic acidosis, electrolyte derangements, and potentially worsens kidney function. 1
• Avoid colloids (hydroxyethyl starch, albumin) as they offer no mortality benefit over crystalloids and are more expensive. 1
• Do not aggressively volume load hypertensive patients without clear evidence of hypovolemia, as this worsens outcomes. 1