Which is better, Ringer's (lactated Ringer's solution) or Normal Saline (0.9% sodium chloride solution)?

From the Guidelines

Ringer's solution is generally better than normal saline for most fluid resuscitation needs, including patients with nonvariceal upper gastrointestinal bleeding (UGIB) and hemodynamic instability, as it causes less kidney injury and has a more physiologic composition. The choice of fluid for resuscitation in patients with UGIB is crucial, and the goal is to restore end-organ perfusion and tissue oxygenation while controlling bleeding 1. Some key points to consider when choosing between Ringer's solution and normal saline include:

• Ringer's solution has an electrolyte composition closer to human plasma, containing sodium, potassium, calcium, chloride, and lactate, which helps maintain physiologic balance.
• Normal saline contains only sodium and chloride ions at concentrations higher than plasma, which can lead to hyperchloremic metabolic acidosis with large volume administration.
• A recent randomized trial in 15,802 critically ill patients found a small reduction in acute kidney injury and a possible small reduction in in-hospital mortality with balanced crystalloids (such as Ringer lactate) vs. saline 1. However, normal saline remains appropriate for specific situations such as hypercalcemia, metabolic alkalosis, or when administering blood products. In the context of UGIB, the most important issue is to stop the bleeding while minimizing hemodynamic compromise, and the choice of fluid should be tailored to the patient's specific condition, with Ringer's solution being the preferred option for most routine fluid replacement needs due to its more physiologic composition 1.

From the Research

Comparison of Ringer's and Normal Saline

• The choice between Ringer's and normal saline for fluid resuscitation has been debated, with some studies suggesting that Ringer's may be a safer and more effective option 2, 3.
• A study published in 2018 found that normal saline can cause metabolic acidosis, vascular and renal function changes, as well as abdominal pain in comparison with balanced crystalloids such as Ringer's 2.
• Another study published in 2022 found that balanced crystalloids, including Ringer's, may reduce the risk of death in patients with non-traumatic brain injury, but increase the risk of death in those with traumatic brain injury 4.
• A study published in 2004 found that albumin and saline had similar outcomes in terms of mortality and organ failure in patients in the intensive care unit 5.
• A study published in 2005 found that a polyelectrolyte solution was as effective as normal saline in terms of volume expansion, but better for correcting acidosis in severely dehydrated infants with acute diarrhea 6.
• A recent study published in 2025 found that initial fluid resuscitation with lactated Ringer's solution was associated with improved survival and more hospital-free days in patients with sepsis-induced hypotension compared to 0.9% saline 3.

Key Findings

• Ringer's may be a safer and more effective option than normal saline for fluid resuscitation in certain patient populations 2, 3.
• Balanced crystalloids, including Ringer's, may have different effects on outcomes depending on the specific patient population 4.
• Normal saline can cause metabolic acidosis and other adverse effects, particularly in comparison with balanced crystalloids 2.
• The choice of fluid for resuscitation should be based on the individual patient's needs and circumstances 2, 4, 3.