Indwelling Pleural Catheter Research Articles

Subcutaneous Emphysema Risk Following Indwelling Pleural Catheter Insertion During Rigid Local Anesthetic Thoracoscopy: Via Thoracoscopy Port Versus Separate Incision Site.

Local anesthetic thoracoscopy (LAT) is important in the diagnosis of unilateral pleural effusions. Indwelling pleural catheters (IPC) can be inserted during LAT if a nonexpandable lung is suspected. Subcutaneous emphysema (SCE) is a known complication and is associated with increased morbidity and length of stay. It is unclear however if the incidence of SCE is affected if IPC is inserted through a separate incision to the LAT port. We aim to establish the incidence and grading of SCE when IPC is inserted during LAT and to determine if the site of IPC placement influences this. Retrospective analysis of LAT electronic records and radiology images over 8 years in a University Hospital. The incidence of SCE was assessed during admission and follow-up with the severity of SCE graded 0 to 4 (0 none; 1 at IPC site; 2 ipsilateral chest wall; 3 ipsilateral neck; 4 contralateral chest wall). 55 combined LAT and IPC procedures were performed. In 28 patients the IPC was inserted through the LAT port and in 27 the IPC was inserted in a separate intercostal space (ICS) to the LAT port. On day zero, the incidence of any SCE was lower if the IPC was inserted using a separate ICS to the LAT port compared with the same site as the LAT port( P =0.01). This was similarly reduced on discharge chest radiographs and subsequent follow-up. IPC insertion at LAT using a separate ICS to the LAT port is associated with a reduction in the incidence of SCE during admission and follow-up.

Incidence of complications from indwelling pleural catheter for pleural effusion: A meta-analysis.

Indwelling pleural catheter (IPC) is widely used in patients with pleural effusion (PE). This meta-analysis aimed to comprehensively summarize the clinical complication from IPC. We searched four large electronic databases (PubMed, EMBASE, MEDLINE, and Cochrane Library) for potentially relevant studies and assessed the included studies' quality using the methodological index for nonrandomized studies' criteria. Extracted data were used to pool rates, and to conduct subgroup and meta-regression analyses. Forty-one studies involving a cumulative 4983 patients with 5650 IPCs were included in this meta-analysis. The overall incidence of IPC complications was 20.3% (95% confidence interval [CI]: 15.0-26.3). The top four complications were: overall infection incidence 5.7% (95% CI: 0.7-2.4); overall catheter abnormality incidence 4.4% (95% CI: 2.8-6.3); pain incidence 1.2% (95% CI: 0.4-2.4); and overall loculation incidence 0.9% (95% CI: 0.1-2.1). Subgroup and meta-regression analyses for overall complications and infections by country, PE site, and PE type demonstrated these factors did not contribute significantly to heterogeneity. Further subgroup analyses for infection of benign PE showed that the overall infection incidence (12.6% [95% CI: 8.1-17.8] vs 0.7% [95% CI: 0.0-4.5]) and empyema incidence (9.1% [95% CI: 5.3-13.8] vs 0.0% [95% CI: 0.0-2.3]) of patients with liver-related PE were significantly higher than that of patients with heart-related PE. Our meta-analysis showed reliable pooled incidences of IPC-related complications, with infection being the most common. These results serve to remind clinicians about the incidence of IPC-related complications and emphasize the importance of taking corresponding preventive and therapeutic steps.

Indwelling tunneled pleural catheters in patients with hepatic hydrothorax: A single-center analysis for outcomes and complications

Rationale Patients with refractory hepatic hydrothorax (HH) are challenging to manage due to associated risks involved with repeated procedures required for drainage of the effusion. There is paucity of data describing the role of indwelling pleural catheters (IPC) in HH. We describe our experience with IPCs for management of refractory HH in collaboration with our homecare nursing services. Objective We are describing our Canadian experience using IPCs for HH, focusing on outcomes, safety, and complications to improve the management of this condition. Methods This is a retrospective study of a prospectively maintained database of all patients with HH who underwent IPC insertion between May 2006 and February 2019 at our tertiary center. Patients’ characteristics, procedural variables, outcomes and estimated survival analysis post IPC insertion were analyzed. Measurements and main results A total of 40 patients underwent 43 IPC insertions. Seven catheters (17.5%) resulted in pleural infection, without any associated deaths. Mean pleural fluid protein level was lower among patients who developed pleural infection compared to those who did not (11.5 g/L vs 16 g/L; p = 0.0015). Median survival was 12.7 months (95% CI, 6.4-43.4). Twenty-one catheters were removed within 149 days (+/- 50.2). Twelve patients died with the IPC in-situ within 69.5 days (+/- 48.7). Conclusion In refractory HH, IPCs can be safely used. Associated complications can be mitigated with frequent clinical monitoring and intermittent drainage of the effusion by dedicated homecare nursing services. Further studies establishing the role for prophylactic antibiotics in high-risk population may be of value.

INDWELLING PLEURAL CATHETERS FOR TREATMENT OF RECURRENT PLEURAL EFFUSION DUE TO CONGESTIVE HEART FAILURE: A SINGLE CENTER EXPERIENCE

INDWELLING PLEURAL CATHETERS FOR TREATMENT OF RECURRENT PLEURAL EFFUSION DUE TO CONGESTIVE HEART FAILURE: A SINGLE CENTER EXPERIENCE

ISSUES IN CONTINUITY OF CARE AND COMPLICATIONS IN INDWELLING PLEURAL CATHETER PLACEMENT: A QUALITY IMPROVEMENT STUDY IN A THREE-HOSPITAL NY SYSTEM

ISSUES IN CONTINUITY OF CARE AND COMPLICATIONS IN INDWELLING PLEURAL CATHETER PLACEMENT: A QUALITY IMPROVEMENT STUDY IN A THREE-HOSPITAL NY SYSTEM

Indwelling pleural catheter insertion for the management of malignant pleural effusion: exploring patients’ experiences

Malignant pleural effusion is a complication of advanced cancer that causes distressing dyspnoea (breathlessness). An indwelling pleural catheter (IPC) is an option for the management of recurrent effusions; however, patients’ experiences of IPC treatment have not been studied in detail.This article describes a service evaluation that was undertaken to explore patients’ experiences of IPC treatment when discharged home following insertion. Ten patients with malignant pleural effusion undergoing IPC insertion participated in semi-structured interviews, and the data from these were thematically analysed using the framework method. It was found that most patients reported symptomatic improvement as a result of the IPC, but this did not correlate with functional improvement. One patient had no symptomatic or functional improvement and regretted having the procedure. The IPC was preferred by patients compared with other management interventions they had received previously. Further studies are required to identify which patients are unlikely to experience symptomatic benefit from the use of IPCs.

The Treatment of Malignant Pleural Effusion With Permanent Indwelling Pleural Catheters.

40 000 to 60 000 people develop malignant pleural effusion (MPE) in Germany each year. The most common causes are lung cancer and breast cancer. Patients with pleural carcinomatosis have a median survival time of four months. We investigated the current health services situation regarding treatment with indwelling pleural catheters (IPC) versus talc pleurodesis (TP) in Germany based on registry data from the Federal Statistical Office, the Pleural Tumor Registry of the German Society for Thoracic Surgery, and the IPC registry of the ewimed GmbH company. In addition, we conducted a selective literature review on IPC and TP. The symptoms of dyspnea and thoracic pressure determine the need for therapy in MPE. Both TP and IPC are effective treatment options for MPE. Both therapeutic procedures are considered equally effective with respect to the relief of dyspnea, post-interventional quality of life, and complication rates. TP yields a higher rate of successful pleurodesis than IPC (relative risk: 1.56; 95% confidence interval: [1.26; 1.92]; p < 0.0001), while patients who receive an IPC stay in the hospital for a shorter time than those who undergo TP (a difference of slightly more than two days). The survival of patients with MPE is not affected by which of the two local therapeutic procedures is chosen. The indication for either IPC or TP needs to be determined individually for each patient on the basis of his or her general condition, symptoms, clinical situation ("trapped lung"), and prognosis.

Nonmalignant Pleural Effusions.

Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14-16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. Refractory cardiac and liver-induced pleural effusions portend a poor prognosis. In cases of heart failure-related effusions, therapeutic thoracentesis is the first-line palliative therapy. However, if it is frequently needed, an indwelling pleural catheter (IPC) is recommended. In patients with hepatic hydrothorax, repeated therapeutic thoracenteses are commonly performed while a multidisciplinary decision on the most appropriate definitive management is taken. The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.

Recomendaciones de la Sociedad Española de Cirugía Torácica para el manejo del derrame pleural maligno

This article summarizes the clinical guidelines for the diagnosis and treatment of malignant pleural effusion (MPE) sponsored by the Spanish Society of Thoracic Surgery (SECT). Ten clinical controversies were elaborated under the methodology of PICO (Patient, Intervention, Comparison, Outcome) questions and the quality of the evidence and grading of the strength of the recommendations was based on the GRADE system. Immunocytochemical and molecular analyses of pleural fluid may avoid further invasive diagnostic procedures. Currently, the definitive control of MPE can be achieved either by pleurodesis (talc poudrage or slurry) or the insertion of a indwelling pleural catheter (IPC). It is likely that the combination of both techniques (i.e., thoracoscopy with talc poudrage and insertion of a IPC, or instillation of talc slurry through a IPC) will have a predominant role in the future therapeutic management.

Day-case thoracoscopy: a retrospective analysis

Day case local anaesthetic thoracoscopy (LAT) with indwelling pleural catheter (IPC) insertion is currently being advocated to minimise length of stay in the COVID-19 pandemic. As part of this innovation, continuous service reviews are warranted. All local procedures are performed in theatre. Rapid

Australasian Malignant PLeural Effusion (AMPLE)-3 trial: study protocol for a multi-centre randomised study comparing indwelling pleural catheter (±talc pleurodesis) versus video-assisted thoracoscopic surgery for management of malignant pleural effusion

IntroductionMalignant pleural effusions (MPEs) are common. MPE causes significant breathlessness and impairs quality of life. Indwelling pleural catheters (IPC) allow ambulatory drainage and reduce hospital days and re-intervention rates when compared to standard talc slurry pleurodesis. Daily drainage accelerates pleurodesis, and talc instillation via the IPC has been proven feasible and safe. Surgical pleurodesis via video-assisted thoracoscopic surgery (VATS) is considered a one-off intervention for MPE and is often recommended to patients who are fit for surgery. The AMPLE-3 trial is the first randomised trial to compare IPC (±talc pleurodesis) and VATS pleurodesis in those who are fit for surgery.Methods and analysisA multi-centre, open-labelled randomised trial of patients with symptomatic MPE, expected survival of ≥ 6 months and good performance status randomised 1:1 to either IPC or VATS pleurodesis. Participant randomisation will be minimised for (i) cancer type (mesothelioma vs non-mesothelioma); (ii) previous pleurodesis (vs not); and (iii) trapped lung, if known (vs not). Primary outcome is the need for further ipsilateral pleural interventions over 12 months or until death, if sooner. Secondary outcomes include days in hospital, quality of life (QoL) measures, physical activity levels, safety profile, health economics, adverse events, and survival. The trial will recruit 158 participants who will be followed up for 12 months.Ethics and disseminationSir Charles Gairdner and Osborne Park Health Care Group (HREC) has approved the study (reference: RGS356). Results will be published in peer-reviewed journals and presented at scientific meetings.DiscussionBoth IPC and VATS are commonly used procedures for MPE. The AMPLE-3 trial will provide data to help define the merits and shortcomings of these procedures and inform future clinical care algorithms.Trial registrationAustralia New Zealand Clinical Trial Registry ACTRN12618001013257. Registered on 18 June 2018.Protocol version: Version 3.00/4.02.19

Postoperative outcome after palliative treatment of malignant pleural effusion.

BackgroundThe objective of this nationwide, registry‐based study was to compare the two most frequently used procedures for the palliative treatment of a malignant pleural effusion (MPE) and to evaluate differentiated indications for these two procedures.MethodsThis was a retrospective observational study based on data of the “PLEURATUMOR” registry of the German Society for Thoracic Surgery. Patients who were documented in the period from January 2015 to November 2021 and had video‐assisted thoracic surgery (VATS) talc pleurodesis or implantation of an indwelling pleural catheter (IPC) were included.ResultsA total of 543 patients were evaluated. The majority suffered from secondary pleural carcinomatosis (n = 402; 74%). VATS talc pleurodesis (n = 361; 66.5%) was performed about twice as often as IPC implantation (n = 182; 33.5%). The duration of surgery was significantly shorter in IPC‐patients with 30 min compared to VATS talc pleurodesis (38 min; p = 0.000). Postoperative complication rate was 11.8% overall and slightly higher after VATS talc pleurodesis (n = 49; 13.6%) than after IPC implantation (n = 15; 8.2%). After VATS talc pleurodesis patients were hospitalized significantly longer compared to the IPC group (6 vs. 3.5 days; p = 0.000). There was no significant difference in postoperative wound infections between the groups (p = 0.10). The 30‐day mortality was 7.9% (n = 41).ConclusionThe implantation of an IPC can significantly shorten the duration of surgery and the hospital stay. For this reason, the procedure should be matched with the patient's expectations preoperatively and the use of an IPC should be considered not only in the case of a trapped lung.

Recommendations of the Spanish Society of Thoracic Surgery for the management of malignant pleural effusion

This article summarizes the clinical guidelines for the diagnosis and treatment of malignant pleural effusion (MPE) sponsored by the Spanish Society of Thoracic Surgery (SECT). Ten clinical controversies were elaborated under the methodology of PICO (Patient, Intervention, Comparison, Outcome) questions and the quality of the evidence and grading of the strength of the recommendations was based on the GRADE system. Immunocytochemical and molecular analyses of pleural fluid may avoid further invasive diagnostic procedures. Currently, the definitive control of MPE can be achieved either by pleurodesis (talc poudrage or slurry) or the insertion of a indwelling pleural catheter (IPC). It is likely that the combination of both techniques (i.e., thoracoscopy with talc poudrage and insertion of a IPC, or instillation of talc slurry through a IPC) will have a predominant role in the future therapeutic management.

A moving target: Multiples occurrences of left lung torsion secondary to adenocarcinoma and pleural effusion

A patient with left upper lobe adenocarcinoma was found to have asymptomatic left lung torsion in the context of a pleural effusion. With drainage of the pleural effusion the mass returned to its original position. Multiple torsion events were documented and found to only occur in presence of a pleural effusion. This case suggests a new possible indication for indwelling pleural catheter (IPC) placement.

The efficacy and safety of intrapleural hyperthermic perfusion in patients with malignant pleural effusion undergoing video-assisted thoracic surgery: a single-arm clinical trial.

BackgroundPatients with malignant pleural effusion (MPE) are usually treated with an indwelling pleural catheter (IPC) or pleurodesis. However, most do not achieve a satisfactory control rate of pleural effusion and have poor prognosis. Distilled water has cytocidal effects of hypotonic shock and can result in the lysis of cancer cells which was used in surgery to eradicate cancer cells. However, there is no study focusing on the efficacy of intrapleural hyperthemic perfusion for MPE under video-assisted thoracoscopic surgery (VATS). This study explored the efficacy and safety of intrapleural hyperthermic perfusion (IHP) with distilled water in patients with MPE.MethodsIn this retrospective, single-arm trial, patients admitted to department of cardiothoracic surgery of Taizhou hospital and diagnosed with MPE caused by non-small cell lung cancer from January 2014 and December 2018 were included. The clinical characteristics including age, gender smoking history, Karnofsky score, volume of pleural effusion, TNM cancer stage, pathology, genetic test of patients were collected. Patients were treated with hyperthermic perfusion. The pleural cavity was perfused with 43.0 ℃ distilled water for 60 minutes under video-assisted thoracic surgery (VATS). The efficacy of treatment was defined as follows: (I) complete remission (CR; no recurrence of pleural effusion after IHP for at least four weeks); (II) partial remission (PR; pleural effusion was decreased by 50% and the condition lasted for 4 weeks; or (III) no remission (NR; no decrease in pleural effusion). Kaplan-Meier method with a log-rank test was used for survival analysis. Cox proportional hazards regression models were applied to perform univariate and multivariate analysesResultsFrom January 2014 through December 2018, 30 patients with MPE caused by non-small cell lung cancer (NSCLC) were treated with hyperthermic perfusion. There were no serious reportable clinical complications associated with the procedure. The response rate was 96.7%, with 63.3% experiencing PR and 33.3% achieving CR. The overall survival (OS) ranged from 2 to 46 months. The median survival was 12 months.ConclusionsIHP proved to be a feasible and safe strategy for patients with MPE in our study but it still needs to be verified with a larger, prospective and randomized trial in the future.

Diagnosis and Management of Malignant Pleural Effusion: A Decade in Review.

Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality. Treatment is mainly palliative, with symptomatic management achieved via effusion drainage and pleurodesis. Pleurodesis may be hastened by administering a sclerosing agent through a thoracostomy tube, thoracoscopy, or an indwelling pleural catheter (IPC). Over the last decade, several randomized controlled studies shaped the current management of MPE in favor of an outpatient-based approach with a notable increase in IPC usage. Patient preferences remain essential in choosing optimal therapy, especially when the lung is expandable. In this article, we reviewed the last 10 to 15 years of MPE literature with a particular focus on the diagnosis and evolving management.

Silver Nitrate-coated versus Standard Indwelling Pleural Catheter for Malignant Effusions: The SWIFT Randomized Trial.

Rationale: Tunneled, indwelling pleural catheters (IPCs) have been demonstrated to be an effective method of managing malignant pleural effusions. However, they allow pleurodesis and can therefore be removed in only a subset of patients. A novel, silver nitrate-coated IPC was developed with the intention of creating a rapid, effective chemical pleurodesis to allow more frequent and earlier catheter removal. This study represents the pivotal clinical trial evaluating that catheter versus the standard IPC. Objectives: To compare the efficacy of a novel silver nitrate-eluting indwelling pleural catheter (SNCIPC) with that of a standard, uncoated catheter. Methods: The SWIFT [A Pivotal Multi-Center, Randomized, Controlled, Single-Blinded Study Comparing the Silver Nitrate-Coated Indwelling Pleural Catheter (SNCIPC) to the Uncoated PleurX® Pleural Catheter for the Management of Symptomatic, Recurrent, Malignant Pleural Effusions] trial was a multicenter, parallel-group, randomized, controlled, patient-blind trial. Central randomization occurred according to a computer-generated schedule, stratified by site. Recruitment was from 17 secondary or tertiary care hospitals in the United States and 3 in the United Kingdom and included adult patients with malignant pleural effusion needing drainage, without evidence of lung entrapment or significant loculation. The intervention group underwent insertion of an SNCIPC with maximal fluid drainage, followed by a tapering drainage schedule. The control group received a standard, uncoated catheter. Follow-up was conducted until 90 days. The primary outcome measure was pleurodesis efficacy, measured by fluid drainage, at 30 days. Results: A total of 119 patients were randomized. Five withdrew before receiving treatment, leaving 114 (77 SNCIPC, 37 standard IPC) for analysis. The mean age was 66 years (standard deviation, 11). More patients in the SNCIPC group were inpatients (39% vs. 14%; P = 0.009). For the primary outcome, pleurodesis rates were 12 (32%) of 37 in the control group and 17 (22%) of 77 in the SNCIPC group (rate difference, -0.10; 95% confidence interval, -0.30 to 0.09). Median time to pleurodesis was 11 days (interquartile range, 9 to 23) in the control group and 4 days (interquartile range, 2 to 15) in the SNCIPC group. No significant difference in treatment-related adverse event rates was noted between groups. Conclusions: The SNCIPC did not improve pleurodesis efficacy compared with a standard IPC. This study does not support the wider use of the SNCIPC device. Clinical trial registered with www.clinicaltrials.gov (NCT02649894).

Modified indwelling pleural catheter versus silver nitrate pleurodesis for the management of malignant pleural effusion

Background About half of the patients suffering from malignant pleural effusion (MPE) complain of dyspnea with poor quality of life. Objective The aim of this study was to compare the efficacy and safety of silver nitrate pleurodesis (SNP) via tube thoracostomy and modified indwelling pleural catheter (IPC) in the management of patients complaining of recurrent symptomatic MPE. Patients and methods This two-arm, nonblinded interventional study (randomized controlled trial) was conducted between April 2018 and October 2019. In all, 45 patients were involved in this study and were randomly divided into two groups. Group I (SNP via tube thoracostomy, SNP group) including 21 patients and group II (modified IPC, IPC group) including 24 patients. Findings All enrolled patients had either moderate or massive pleural effusions. The majority of cases (61.9% of the SNP group and 69.6% of the modified IPC group) had successful pleurodesis. Mean hospital stay was significantly lower among the modified IPC group in comparison to the SNP group. The modified IPC group had a significantly higher chest pain score and higher dyspnea score at 1-month postprocedure in comparison to the SNP group. Interpretation SNP via intercostal tube and modified IPC pleurodesis for the management of recurrent symptomatic MPE were nearly equally effective with a high success rate and low tolerable complications. Both methods were safe and inexpensive in the achievement of pleurodesis. Modified IPC pleurodesis had the advantage of a single-day procedure and shorter hospital stay.

Pleural Effusions and Pericarditis: A Retrospective Cohort Study of Patients Undergoing Cardiac Magnetic Resonance Imaging.

BackgroundPleural effusions can occur due to acute pericarditis and can necessitate intervention. We sought to add to the evidence base by performing a retrospective review of patients presenting to the advanced cardiac imaging unit with pericarditis and pleural effusion to determine laterality, trends in pleural fluid analyses, and the need for pleural intervention. Local ethical (Caldicott) approval was obtained for this study.MethodologyDescriptive statistical methodology was applied with continuous data presented as mean (standard deviation, SD; range) and categorical variables as frequencies or percentages.ResultsIn 60 patients with pericarditis, 24 (39%) had pleural effusions on contemporaneous imaging. The mean age of the study population was 63.3 years (range: 20-83), and 17 patients were males. Diagnoses were viral (five), rheumatological (one), amyloidosis (one), listeria (one), and the rest idiopathic (17). Four effusions were only left-sided, one right-sided, and 20 bilateral. Ten pleural taps were performed, one for a unilateral effusion and nine for one side being bigger than the other. The mean pH was 7.46 (7.33-7.6), mean lactate dehydrogenase was 210 (74-393 U/L), mean fluid protein was 36.1 (19-56 g/L) (four effusions exudative/three transudative), mean glucose was 5.8 (4.8-6.8 mmol/L), and all cytologies were negative. Five patients underwent large volume aspirations for symptom control. Three indwelling pleural catheters (IPC) were placed for treatment refractory effusions. There was one pleural space infection in six months related to an IPC. There were three deaths at 12 months, with none related to pericarditis.ConclusionsPleural effusions associated with pericarditis are usually small, bilateral, and exudative. Treatment refractory cases require pleural intervention, with aspirations, drains, and IPCs being viable options. Further prospective studies are warranted.

Michele — This Is My Why, Now Let's Find the Way…

After a protracted hospital course for the management of cardiogenic shock in my home country of Venezuela, Michele was discharged with the hope for native heart recovery. The next several months would prove to be grueling—he had recently lost medical insurance coverage, so as a very close family friend I took responsibility for leading his medical care. Hypotension limited medical options and recurrent pleural effusions, unresponsive to diuretic therapy, quickly became a challenge. With only rudimentary supplies available to us, colleagues and I performed repeated thoracenteses while the family worked around hurdles to get an indwelling pleural catheter delivered from the United States. The need for advanced heart failure therapies became abundantly clear, and this turned out to be the first time I found myself doing extensive research on durable left ventricular assist devices and heart transplantation—almost 10 years ago now. Together with his family, we contacted several institutions outside of the country (including in Italy, his native country) to inquire about heart transplant candidacy criteria for international residents—the process was disheartening. One night I received a call that Michele was acutely short of breath and had become increasingly lethargic. I happened to be working a night shift in a nearby emergency department, so the family immediately brought him over. He arrived in pulseless electrical activity. To this day, it has been the most difficult code I have ever had to run and terminating resuscitation attempts was devastating. I witnessed many tragic events during my training and early years in medical practice in Venezuela, but recognizing that Michele's care was largely dictated by where he lived still haunts me.