for the BaSICS investigators and the BRICNet members IMPORTANCE Intravenous fluids are used for almost all intensive care unit (ICU) patients. Clinical and laboratory studies have questioned whether specific fluid types result in improved outcomes, including mortality and acute kidney injury.OBJECTIVE To determine the effect of a balanced solution vs saline solution (0.9% sodium chloride) on 90-day survival in critically ill patients. DESIGN, SETTING, AND PARTICIPANTS Double-blind, factorial, randomized clinical trial conducted at 75 ICUs in Brazil. Patients who were admitted to the ICU with at least 1 risk factor for worse outcomes, who required at least 1 fluid expansion, and who were expected to remain in the ICU for more than 24 hours were randomized between May 29, 2017, and March 2, 2020; follow-up concluded on October 29, 2020. Patients were randomized to 2 different fluid types (a balanced solution vs saline solution reported in this article) and 2 different infusion rates (reported separately).INTERVENTIONS Patients were randomly assigned 1:1 to receive either a balanced solution (n = 5522) or 0.9% saline solution (n = 5530) for all intravenous fluids. MAIN OUTCOMES AND MEASURESThe primary outcome was 90-day survival. RESULTS Among 11 052 patients who were randomized, 10 520 (95.2%) were available for the analysis (mean age, 61.1 [SD, 17] years; 44.2% were women). There was no significant interaction between the 2 interventions (fluid type and infusion speed; P = .98). Planned surgical admissions represented 48.4% of all patients. Of all the patients, 60.6% had hypotension or vasopressor use and 44.3% required mechanical ventilation at enrollment. Patients in both groups received a median of 1.5 L of fluid during the first day after enrollment. By day 90, 1381 of 5230 patients (26.4%) assigned to a balanced solution died vs 1439 of 5290 patients (27.2%) assigned to saline solution (adjusted hazard ratio, 0.97 [95% CI, 0.90-1.05]; P = .47). There were no unexpected treatment-related severe adverse events in either group.CONCLUSION AND RELEVANCE Among critically ill patients requiring fluid challenges, use of a balanced solution compared with 0.9% saline solution did not significantly reduce 90-day mortality. The findings do not support the use of this balanced solution.

for the BaSICS investigators and the BRICNet members IMPORTANCE Slower intravenous fluid infusion rates could reduce the formation of tissue edema and organ dysfunction in critically ill patients; however, there are no data to support different infusion rates during fluid challenges for important outcomes such as mortality.OBJECTIVE To determine the effect of a slower infusion rate vs control infusion rate on 90-day survival in patients in the intensive care unit (ICU). DESIGN, SETTING, AND PARTICIPANTS Unblinded randomized factorial clinical trial in 75 ICUs in Brazil, involving 11 052 patients requiring at least 1 fluid challenge and with 1 risk factor for worse outcomes were randomized from May 29, 2017, to March 2, 2020. Follow-up was concluded on October 29, 2020. Patients were randomized to 2 different infusion rates (reported in this article) and 2 different fluid types (balanced fluids or saline, reported separately).INTERVENTIONS Patients were randomized to receive fluid challenges at 2 different infusion rates; 5538 to the slower rate (333 mL/h) and 5514 to the control group (999 mL/h). Patients were also randomized to receive balanced solution or 0.9% saline using a factorial design. MAIN OUTCOMES AND MEASURESThe primary end point was 90-day survival.RESULTS Of all randomized patients, 10 520 (95.2%) were analyzed (mean age, 61.1 years [SD, 17.0 years]; 44.2% were women) after excluding duplicates and consent withdrawals. Patients assigned to the slower rate received a mean of 1162 mL on the first day vs 1252 mL for the control group. By day 90, 1406 of 5276 patients (26.6%) in the slower rate group had died vs 1414 of 5244 (27.0%) in the control group (adjusted hazard ratio, 1.03; 95% CI, 0.96-1.11; P = .46). There was no significant interaction between fluid type and infusion rate (P = .98).CONCLUSIONS AND RELEVANCE Among patients in the intensive care unit requiring fluid challenges, infusing at a slower rate compared with a faster rate did not reduce 90-day mortality. These findings do not support the use of a slower infusion rate.

Objective: To compare the impact of single-bed versus multibed room intensive care units (ICU) architectural designs on the stress and burnout of ICU staff and on the stress and satisfaction of family visitors. Background: There are countless architectural variations among ICUs, but all involve single-bed or multibed rooms. Although it is well known that ICU design affects important patient outcomes, the effect of ICU design on family and staff has been insufficiently studied. Methods: Among ICU staff and family visitors, stress was evaluated with Lipp’s Inventory of Stress Symptoms. ICU staff burnout was evaluated with the Maslach Burnout Inventory. Family visitor satisfaction was evaluated with Molter’s Critical Care Family Needs Inventory. Results: Among 156 ICU professionals who were interviewed, similar burnout rates were observed between ICU staff who worked single-bed versus multibed rooms. However, stress reported by ICU staff within the previous 24 hr was higher among the ICU staff who worked in single-bed rooms (14.3% vs. 4.7%, p = .04). Among 176 family visitors who were interviewed, a similar level of stress was reported by family members who visited patients in single-bed or multibed rooms. However, the satisfaction of family members visiting patients in single-bed rooms was higher (96.0% vs. 84.6%, p = .02). Conclusions: Single-bed ICU design was associated with greater satisfaction of family visitors yet with higher levels of stress for ICU staff. Meanwhile, similar burnout levels were observed for ICU staff who worked in single-bed or multibed rooms.

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Objective To describe the use of neuromuscular blockade as well as other practices among Brazilian physicians in adult intensive care units. Methods An online national survey was designed and administered to Brazilian intensivists. Questions were selected using the Delphi method and assessed physicians’ demographic data, intensive care unit characteristics, practices regarding airway management, use of neuromuscular blockade and sedation during endotracheal intubation in the intensive care unit. As a secondary outcome, we applied a multivariate analysis to evaluate factors associated with the use of neuromuscular blockade. Results Five hundred sixty-five intensivists from all Brazilian regions responded to the questionnaire. The majority of respondents were male (65%), with a mean age of 38 ( 8.4 years, and 58.5% had a board certification in critical care. Only 40.7% of the intensivists reported the use of neuromuscular blockade during all or in more than 75% of endotracheal intubations. In the multivariate analysis, the number of intubations performed monthly and physician specialization in anesthesiology were directly associated with frequent use of neuromuscular blockade. Etomidate and ketamine were more commonly used in the clinical situation of hypotension and shock, while propofol and midazolam were more commonly prescribed in the situation of clinical stability. Conclusion The reported use of neuromuscular blockade was low among intensivists, and sedative drugs were chosen in accordance with patient hemodynamic stability. These results may help the design of future studies regarding airway management in Brazil.

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Since the 1980s, the number of Pentecostal candidates elected to the Brazilian legislatures has grown remarkably. Literature has argued that the phenomenon is related to Pentecostal churches' support for particular candidates. To date, however, this claim has been based only on ethnographies or studies relying on a few cases of elected candidates. Drawing from a new data set of Evangelical (Protestant) candidates for the Federal Chamber of Deputies and state legislative assemblies, I try to answer the following questions: Do Pentecostal candidates raise fewer campaign resources than other candidates? What is the effect of being a Pentecostal candidate on the vote in Brazilian legislative elections? Is the structure of the church relevant to this effect? Using OLS regression models, I show that being a Pentecostal has a negative, though not significant effect on campaign spending. Additionally, there is a positive statistical relationship between being a Pentecostal and receiving votes, and between having the support of more centralized churches and receiving votes. Qualitative evidence of six Pentecostal politicians who lost their churches' support at some point between elections, attempted reelection, and performed considerably worse than before reinforces the importance of having the support of a Pentecostal church. the JPLA anonymous reviewers for their helpful comments. Any remaining errors are mine alone. Some of the material presented here was delivered at seminars at the University of São Paulo and at the 41st Annual Meeting of ANPOCS in Caxambu, Brazil. The data set and replication materials are available from the author upon request.

Qual é o desempenho dos candidatos evangélicos nas eleições para o legislativo no Brasil? Seriam as candidaturas pentecostais responsáveis pela representação política dos evangélicos? Teriam as igrejas pentecostais um alto grau de sucesso eleitoral? A influência de evangélicos na política brasileira vem ganhando crescente destaque na mídia e na academia. Ela é consequência da rápida expansão do pentecostalismo no Brasil. A literatura prévia assumiu que candidatos pentecostais controlariam seus fiéis como um “rebanho eleitoral”. A partir de uma discussão conceitual sobre o candidato evangélico e sua relação com a igreja e de um novo banco de dados de candidaturas evangélicas, apresento evidências de que a proporção de candidaturas evangélicas se manteve estável na última década; os políticos pentecostais representam a grande maioria dos políticos evangélicos nos legislativos brasileiros; mas, a despeito disso, o sucesso eleitoral das igrejas pentecostais não é forte como se assevera.