Cardiac arrest and post-ROSC care

Temperature control after cardiac arrest

Reviewed Nov 2026·5 references
New· views rounded down, updated weekly

In patients who remain comatose after ROSC, actively prevent fever (≤ 37.5 °C) for at least 72 h. Hypothermia at 32-36 °C is acceptable but not proven better.

At the bedside

Timed steps
  1. 1

    Identify eligible patients

    0-1 h

    Any adult not following commands after ROSC, regardless of rhythm or location.

  2. 2

    Measure core temperature

    0-1 h

    Bladder, oesophageal or blood (PA/femoral catheter) probe. Avoid axillary readings.

  3. 3

    Choose target

    Start

    ERC-ESICM: actively prevent fever, keeping temperature ≤ 37.5 °C. AHA: choose and maintain a constant temperature between 32 and 37.5 °C.

  4. 4

    Devices

    Start

    Feedback-controlled surface or intravascular device if available. Otherwise cold packs, cooling blankets, fans, paracetamol. No prehospital cold IV fluid boluses.

  5. 5

    Sedation and shivering

    Throughout

    Short-acting sedation (propofol, fentanyl/remifentanil); manage shivering (Bedside Shivering Assessment Scale) with skin counter-warming, magnesium, opioids, dexmedetomidine; neuromuscular block as last resort.

  6. 6

    Duration

    ≥ 36-72 h

    AHA: ≥ 36 h; ERC-ESICM: prevent fever for at least 72 h.

  7. 7

    Slow

    Rewarming

    If cooled below 36 °C: rewarm ≤ 0.25-0.5 °C/h; continue to prevent fever after rewarming. Do not actively rewarm patients with mild spontaneous hypothermia (32-36 °C) (ERC).

Key temperature trials

TrialPopulationComparisonResult
TTM1 (2013)OHCA, all rhythms, n=95033 vs 36 °CNo difference in mortality or neurological outcome
HYPERION (2019)Non-shockable, OHCA and IHCA, n=58433 °C vs 37 °CBetter neurological outcome at 90 days with 33 °C (10.2% vs 5.7%); fragile result
TTM2 (2021)OHCA, n=190033 °C vs normothermia with fever prevention (≤ 37.8 °C)No difference in 6-month mortality; more arrhythmias with hypothermia
Red flag · call your senior now
Fever > 37.7 °C in a comatose post-arrest patient: treat promptly; it is associated with worse outcome.
Red flag
Bradycardia < 40/min, arrhythmia or bleeding during hypothermia: consider warming to a higher target.
Pitfall
Stopping temperature control at 24 h and allowing rebound fever.
Pitfall
Unrecognised shivering raises metabolic rate and temperature: assess it every hour.
Pearl
Hypothermia causes cold diuresis, hypokalaemia, hyperglycaemia and slower drug clearance; rewarming causes K+ to rise.

References

  1. 1

    Part 11: Post-Cardiac Arrest Care: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025

  2. 2

    Nolan JP, Sandroni C, Cariou A, et al. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2025: post-resuscitation care. Intensive Care Med. 2025;51(12):2213-2288

  3. 3

    Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013;369(23):2197-2206

  4. 4

    Dankiewicz J, Cronberg T, Lilja G, et al. Hypothermia versus normothermia after out-of-hospital cardiac arrest (TTM2). N Engl J Med. 2021;384(24):2283-2294

  5. 5

    Lascarrou JB, Merdji H, Le Gouge A, et al. Targeted temperature management for cardiac arrest with nonshockable rhythm (HYPERION). N Engl J Med. 2019;381(24):2327-2337

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