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 adopted, i.e. the the ultrasound-guided placement of a catheter whose tip arrives in the superior vena cava or in the inferior vena cava or in the right atrium.
All current guidelines strongly recommend the use of ultrasound even in emergency-urgency. It has been demonstrated that ultrasound-guided venipuncture reduces times and risks - if compared to 'blind' maneuvers - also in the emergency setting.
The placement of a peripherally inserted central catheter (PICC) is almost never indicated in emergency, because of the longer time required for the maneuver and for the reduced costeffectiveness (emergency catheters must be removed within 24-48 hours). Thus, we should choose between a centrally inserted central catheter (CICC) and a
femorally inserted central catheter (FICC); this choice depends on several factors: the presence of local pathological issues that can hinder or make difficult the maneuver (i.e.: cervico-thoracic trauma),the more or less adequate ultrasound visualization of the veins above/below the clavicle (internal jugular, subclavian, brachio-cephalic, axillary) compared to the visualization of the femoral vein, 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. ATLS (Advanced Trauma Life Support) recommends 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 these emergency catheters must be removed within 24-48 hours.
The emergency FICC will usually have the tip in the inferior vena cava (ideal position: above the bifurcation of the iliacs, under the bifurcations of the renals - surface landmark being the navel): as such, it will be usable for infusions of any type and for blood sampling, but not for hemodynamic monitoring.