Carina as a useful and reliable radiological landmark for detection of accidental arterial placement of central venous catheters

Central venous catheters are commonly used in the management of critically ill patients. Their insertion can be challenging in hemodynamically unstable patients and in those with altered thoracic anatomy. Although ultrasound guided insertion can reduce this problem, this facility may not be available in all locations and in all institutions. Accidental arterial puncture is one of the very serious complications that can occur during central venous catheter insertion. This is usually detected clinically by bright color and projectile/pulsatile flow of the returning blood. However, such means are known to be misleading especially in hypoxic and hemodynamically unstable patients. Other recognized measures used to identify arterial puncture would be blood gas analysis of the returning blood, use of pressure transducer to identify waveform pattern and the pressures. In this article, we propose that trachea and carina can be used as a reliable radiological landmark to identify accidental arterial placement of central venous catheters. We further conclude that this information could be useful especially when dealing with post-resuscitation victims and hemodynamically unstable critically ill patients.