Written by Chris Thom
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In this randomized control trial of hypotensive ED patients, a blood pressure cuff was associated with greater basilic vein diameter on ultrasound and higher first-pass peripheral IV success than a standard elastic tourniquet.
The vein is bigger with the BP cuff
This was a single-center RCT comparing elastic tourniquets (ET) with blood pressure cuffs (BPC) in a cohort of hypotensive ED patients. Patients received either ET or BPC applied to the upper arm above the elbow. They were then fitted with a garment that effectively concealed this area. A study investigator with ultrasound training performed an assessment of the basilic vein just proximal to the basilic vein bifurcation (see accompanying image) before and after ET or BPC placement. The diameter of the basilic vein before and after was recorded, along with compressibility of the vessel. The nurse then performed landmark peripheral IV (PIV) placement of the basilic vein while the ET or BPC was attached to the upper arm.
The median change in diameter of the basilic vein was 0.4 mm (IQR 0.2-0.6) in the ET group and 1.2 (IQR 0.5-2.0) in the BPC group, p<0.0001. First-stick IV success was seen in 41% in the ET group and 63% in the BPC group, p=0.02. A higher compressibility of the basilic vein was noted in the ET group as compared to the BPC group.
How will this change my practice?
We have access to tools that could make everyday procedures a bit easier and more successful. This trial is a bit limited in that the investigators focused on just one area of a single vein. However, given how common peripheral IV placement is in EM (easily our most common procedure), this new evidence matters. The BP cuff setting used here was 60 mm Hg, which is also an important variable to note. On my next difficult access case where the veins look particularly challenging under ultrasound, I may well pull out the manual BP cuff to see if that extra venous distension will prove useful with ultrasound guided PIV access.
POCUS Pro-Tips and Clips:
The basilic vein is one of my favorite targets for ultrasound-guided PIV access. It runs a straighter and more consistent course in the upper arm than the brachial and cephalic options (see image). It resides more medially than is ideal, so I tend to have patients significantly externally rotate or even place the arm above their head and evaluate from the head of the bed. For the ultrasound approach, I tend to start with the short axis approach first to get the catheter midline into the vessel, followed by an active rotation to the long axis to adjust pitch and depth before catheter thread. More on that approach in this terrific educational resource in additional reference below.
Another Spoonful
Don’t miss this video: Ultrasound Guided IV Placement. Academy of Emergency Ultrasound.
Source
Comparison of elastic tourniquet and blood pressure cuff for peripheral intravenous access in hypotensive patients: a randomized single-blind study. The Journal of Emergency Medicine. 2025.
