Is interposed abdominal cardiopulmonary resuscitation (CPR) still a recommended approach?

Is Interposed Abdominal CPR Still Appropriate or Novel?

Interposed abdominal compression CPR (IAC-CPR) is neither novel nor routinely recommended—it remains a Class IIb (may be considered) technique that has not been updated since 2010 and has not been studied in humans since 1994. 1

Current Guideline Status

The American Heart Association has maintained the same recommendation since 2010 without revision through the 2015 guidelines update: IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb, LOE B). 1

This recommendation was explicitly not reviewed in 2015, meaning it has remained unchanged for over a decade despite the evolution of other CPR techniques. 1

Why IAC-CPR Is Not Routinely Recommended

Evidence Limitations

• The last human study of IAC-CPR was conducted in 1994—over 30 years ago. 1
• While two randomized in-hospital trials showed improved short-term survival and survival to hospital discharge compared to conventional CPR, one randomized controlled trial of out-of-hospital cardiac arrest showed no survival advantage. 1
• The evidence base consists primarily of small to medium-sized studies from the early 1990s. 2, 3

Practical Barriers

• IAC-CPR requires three trained rescuers: one for chest compressions, one for ventilations, and one dedicated to abdominal compressions. 1
• The technique demands coordination and specific training that most resuscitation teams do not routinely possess. 1
• Most reports indicate an endotracheal tube should be placed before or shortly after initiation, adding another procedural requirement. 1

When IAC-CPR Might Be Considered

In-Hospital Setting Only

IAC-CPR should only be considered for in-hospital cardiac arrest when you have sufficient trained personnel available. 1

The evidence supporting this limited recommendation includes:

• Return of spontaneous circulation improved from 27-28% with standard CPR to 49-51% with IAC-CPR in in-hospital trials. 2, 3
• Survival to hospital discharge increased from 7% to 25% in one randomized trial. 2
• Particularly effective for asystole and electromechanical dissociation, where 24-hour survival improved from 13% to 33%. 3

Settings Where It Should NOT Be Used

• Out-of-hospital cardiac arrest: There is insufficient evidence to recommend for or against use. 1
• Children: Insufficient evidence, and one pediatric case report documented traumatic pancreatitis following IAC-CPR. 1
• Unintubated patients: Most successful protocols involved early endotracheal intubation. 4

The Technique (If You Choose to Use It)

• Compress the abdomen midway between the xiphoid and umbilicus during the relaxation phase of chest compression. 1
• Hand position, depth, rhythm, and rate mirror chest compressions (80-100/min). 1, 2
• Force required is similar to that used to palpate the abdominal aorta. 1
• The abdominal compression occurs during CPR diastole, alternating with chest compressions. 2, 3

Mechanism of Benefit

IAC-CPR works by:

• Increasing diastolic aortic pressure and venous return. 1
• Improving coronary perfusion pressure and blood flow to vital organs. 1, 4
• Enhancing mean perfusion pressure due to differences in venous and arterial capacitance. 5

Safety Profile

• No complications were reported in adults in the published series through 2010. 1
• Minimal possible harm based on 426 humans who received IAC in published reports. 6
• One pediatric case of traumatic pancreatitis is the only documented complication. 1

Bottom Line for Clinical Practice

Manual chest compressions remain the standard of care. 7 IAC-CPR is an outdated technique that showed promise in small 1990s-era trials but has been abandoned by the resuscitation community due to resource requirements, lack of contemporary evidence, and the emergence of mechanical CPR devices that can be deployed with fewer personnel. 7

If you work in a hospital with a dedicated resuscitation team that has specifically trained in IAC-CPR and you have three available rescuers, you may consider it—but this scenario is increasingly rare in modern practice. 1 The technique is neither novel (last studied 30 years ago) nor appropriate for routine use (Class IIb recommendation unchanged since 2010). 1