Critically ill patients can be considered not only patients with one or more impaired vital functions but also patients with any severe chronic disease impairing vital signs. The choice of veins is crucial in those patients because their veins’ patrimony could already be poor because of previous therapies and the need for a central venous line could be the only solution. The use of peripheral deep veins in the arm for PICC insertion was rediscovered in the last 20 years with the introduction of ultrasound guidance and the use of new materials such as very flexible and power-injectable polyurethanes and the use of nitinol guide wires. An ultrasound examination of those veins should be performed in order to assess their patency with the compressive ultrasound two-dimensional technique or with the Doppler technique in case of doubts. The choice of the vein in which to insert a PICC line should be guided by cross-sectional diameter of the vein, vein depth, catheter/vein ratio, and exit site. Those parameters together with a proper indication for a PICC line should be followed according to an algorithm for any patient requiring long-term therapy avoiding the risk of a traditional central line insertion.
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