Temperature Management after Cardiac Arrest — All In or Fold?

This editorial examines the evolving evidence base for temperature management following out-of-hospital cardiac arrest, focusing on the optimal target and duration of fever prevention. It discusses findings from the BOX trial subanalysis and prior randomized trials (TTM, TTM2) comparing therapeutic hypothermia (32–34℃ or 33℃) and normothermia (≤37.5℃), revealing no clear outcome advantage. The BOX trial randomized patients to 36℃ fever prevention for either 36 or 72 hours, with no significant differences in death, disability, or coma at 90 days. Retrospective studies also show early fever (>38℃) may not worsen outcomes. International guidelines still recommend temperature control for 72 hours, despite limited data and potential downsides such as prolonged sedation and mechanical ventilation. The authors advocate future trials comparing active fever prevention with no intervention, alongside testing rapid cooling strategies (e.g., prehospital or emergency department induction). Preliminary data suggest methods like transnasal evaporative cooling and ice pack coverage might improve neurologic recovery if implemented swiftly post-resuscitation

This editorial examines the evolving evidence base for temperature management following out-of-hospital cardiac arrest, focusing on the optimal target and duration of fever prevention. It discusses findings from the BOX trial subanalysis and prior randomized trials (TTM, TTM2) comparing therapeutic hypothermia (32–34℃ or 33℃) and normothermia (≤37.5℃), revealing no clear outcome advantage. The BOX trial randomized patients to 36℃ fever prevention for either 36 or 72 hours, with no significant differences in death, disability, or coma at 90 days. Retrospective studies also show early fever (>38℃) may not worsen outcomes. International guidelines still recommend temperature control for 72 hours, despite limited data and potential downsides such as prolonged sedation and mechanical ventilation. The authors advocate future trials comparing active fever prevention with no intervention, alongside testing rapid cooling strategies (e.g., prehospital or emergency department induction). Preliminary data suggest methods like transnasal evaporative cooling and ice pack coverage might improve neurologic recovery if implemented swiftly post-resuscitation