Our team had a very troubling situation this past weekend and we are searching for best practice guidelines. We were called to place a PICC in an ICU patient for "possible pressors". The patient had two old graft sites in the left arm, one old graft in the right arm, and a hemodialysis Shiley catheter to the right chest. We were told none of the old grafts were functional. We recommended different central line placement as we did not feel it was appropriate to try to PICC this patient. We DID look with the ultrasound and saw torturous paths. The renal physician gave his blessing but we recommended against this. We also recommended that the patient go to interventional radiology. We were then ordered by the attending physician to place the line anyhow. On the third attempt, the line was able to be placed by us. Needless to say, we were scared out of our minds. We have always been under the impression that this is not best practice and should always be avoided. Now that this precedent has been set, we fear that we will be asked to do this regularly. Does anyone know of anything in the literature that addresses this? Many thanks.