In some emergency-urgency situations, an ultrasound-guided peripheral venous access may not be feasible or not sufficient or not advisable. In these cases, an ultrasound-guided central venous access is used (ultrasound-guided insertion of a catheter whose tip arrives in the superior vena cava or in the inferior vena cava or in the right atrium).
It should be remembered that the guidelines strongly recommend the use of ultrasound guided venous access also in emergency-urgency. It has been demonstrated that even in urgency ultrasound-guided venipuncture allows to reduce times and risks if compared to 'blind' maneuvers.
The placement of a peripherally inserted central catheter (PICC) is never indicated in emergency, both beacuse of the longer time required for the maneuver and for the reduced cost-effectiveness (as these are catheters to be removed within 24-48 hours). The choice between a centrally inserted central catheter (CICC) and a femorally inserted central catheter (FICC) is based on several factors: the presence of local issues that can hinder or make difficult the maneuver (for example, in a patient with cervico-thoracic trauma), the adequate ultrasound visualization of the veins above/below the clavicle (internal jugular, subclavian, brachio-cephalic, axillary), the presence of hypovolemia (in the hypovolemic patient the femoral venipuncture will be simpler), or the opportunity to leave the facial-cervical area clear for any resuscitation maneuvers. The recommendations of the ATLS (Advanced Trauma Life Support) recommend the placement of a FICC in the polytrauma patient: the potential higher incidence of FICC-related infections and thrombosis will not be a problem, as they are venous devices to be removed within 24-48 hours.
The FICC positioned in emergency will usually have the tip in the inferior vena cava (ideal position: above the bifurcation of the iliac, under the bifurcations of the renals - surface landmark, the navel): as such, it will be appropriate for infusion of solutions of any type and for blood sampling (but not for hemodynamic monitoring).