Although the number of studies in the literature that address the question of coagulopathy reversal prior to central venous catheter (CVC) insertion is small, and the question has been a difficult one to address with large trials, the issue is an extremely important one. Rather than operating based on experiential data and “gut feelings” (as we often do), a review of the existing literature in the context of my personal experience practicing in an ICU that cares for many patients with coagulopathy leads me to conclude that reversal of coagulopathy should be pursued prior to central line insertion (when feasible to do so). Given the increasing availability of peripherally inserted central catheters for more stable patients, the insertion of traditional central venous lines is increasingly used more exclusively in critically ill patients for monitoring and support in the ICU. Thus, the risk of any mechanical complication is heightened in critically ill patients with coagulopathy who have little reserve to tolerate additional hemodynamic derangements. I will first review the small pool of existing recent literature describing the risks of mechanical complications following central line insertion with ultrasound guidance; then, for comparison, I will briefly review the risks of life-threatening complications for patients after receipt of blood products for reversal of coagulopathy. Finally, I will conclude that the data support my experience and gut feelings that the risk-to-benefit ratio for our critically ill patients favors reversing a coagulopathy prior to central line insertion.