Skip to main content

Are the calf and the thigh reliable alternatives to the arm for cuff non-invasive measurements of blood pressure?


Non-invasive measurement of blood pressure (NIBP) is widely used in the critically ill, the cuff being often placed on the calf or the thigh in case of contraindication for placing it on the arm (wounds, fracture, vascular access, and so forth) [1]. However, this common practice has never been validated. We assessed the reliability of NIBP at these different anatomic sites.


Included: adult ICU patients carrying an arterial catheter. Excluded: mean arterial pressure (MAP) increase >5 mmHg during cuff inflation (inflation-induced pain); nonperception of the distal pulse despite the resolution of an eventual circulatory failure. For each site (arm, calf, thigh (if Ramsay score >4)), three pairs of NIBP and invasive measurements were respectively averaged. Patients in circulatory failure (MAP <65 mmHg and/or skin mottling and/or cathecholamine infusion) underwent a second set of measurements, after hemodynamic intervention (volume expansion and/or initiation and/or increase in catecholamine dosage). The agreement was assessed via a Bland-Altman analysis.


Ten patients were excluded and 11 NIBP measurements failed to display any figure: one patient for each site, eight others for the thigh only. Thus, 150 patients were analyzed (41 ± 26 years, BMI 26 ± 6, SAPS II 46 ± 18, Ramsay score = 5 or 6: 83%, mechanical ventilation 99%), comprising 79 patients with circulatory failure (MAP 70 ± 12 mmHg, norepinephrine (n = 62) 0.3 ± 0.3 μg/kg/minute, epinephrine (n = 2) 0.15 ± 0.14 μg/kg/minute). Absolute value of BP - for MAP measurement, NIBP performed better if the cuff was placed on the arm: bias/upper and lower limits of agreement (mmHg) of 3 ± 5/13/-6, 3 ± 8/18/-12 and 6 ± 7/20/-8 on the arm, the calf and the thigh, respectively. NIBP accuracy was similar in case of (mild) circulatory failure. Whatever the anatomic site, NIBP accuracy was better for MAP than for SAP or DAP. MAP changes - among the 57 patients with circulatory failure who underwent a second set of measurements after hemodynamic intervention, MAP changes (%) were better reflected when the cuff was placed on the arm, rather than on the calf or the thigh: 3 ± 5/12/-7, 3 ± 9/20/-14 and 3 ± 7/17/-10, respectively.


For better reliability of MAP (and its changes) measurements, the cuff should be placed on the arm (if possible) rather than the thigh or the calf.


  1. Chatterjee A, et al.: Crit Care Med. 2010, 38: 2335-2338.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Cite this article

Lakhal, K., Macq, C., Ehrmann, S. et al. Are the calf and the thigh reliable alternatives to the arm for cuff non-invasive measurements of blood pressure?. Crit Care 15 (Suppl 1), P74 (2011).

Download citation

  • Published:

  • DOI:


  • Mean Arterial Pressure
  • Anatomic Site
  • Vascular Access
  • Circulatory Failure
  • Invasive Measurement