Post-resuscitation care after ROSC: oxygenation, blood pressure targets and temperature management according to ERC 2025

Why the phase after ROSC needs its own targets

Post-resuscitation care begins with return of spontaneous circulation (ROSC). It is not an afterthought to resuscitation. Hypoxia, hyperoxia, hypotension, hypo- or hypercapnia and fever can further aggravate hypoxic-ischaemic injury. The joint 2025 guidelines of the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) define specific target ranges for this phase [3]. Many of these can already be implemented during prehospital ROSC care.

The key message according to ERC 2025:

• Immediately: ABCDE assessment and 12-lead ECG
• Oxygenation: SpO₂ 94–98 %
• Ventilation: normocapnia
• Circulation: systolic > 100 mmHg or MAP > 60–65 mmHg
• Identify the cause: ST elevation → cardiac catheterisation
• Temperature: actively prevent fever (≤ 37.5 °C, for at least 72 h)

Airway and ventilation

Securing the airway

In comatose patients, the airway is secured after ROSC. Intubation should be performed by experienced operators. Capnography is mandatory, both to confirm tube placement and for continuous monitoring of ventilation [3].

Oxygenation: avoid hypoxia and hyperoxia

The oxygenation target according to ERC 2025 is an SpO₂ of 94–98 % [3]. In practice:

• Start with 100 % oxygen.
• Titrate down as soon as SpO₂ or blood gas analysis (BGA) is reliably available.
• Avoid hypoxia and hyperoxia alike.

Pulse oximetry is less accurate in patients with darker skin pigmentation. In these patients, oxygenation should be checked early by blood gas analysis.

Ventilation: aim for normocapnia

The target is normocapnia with a PaCO₂ of approx. 35–45 mmHg [3]. Three points should be considered:

• etCO₂ as a surrogate for PaCO₂: After resuscitation, etCO₂ often underestimates PaCO₂. Ventilation should therefore be guided by blood gas analysis as soon as possible.
• Hypothermia: Hypothermia carries a risk of hypocapnia. Ventilator settings must be adjusted accordingly.
• Lung-protective ventilation: 6–8 ml/kg predicted body weight.

Haemodynamic stabilisation: blood pressure targets according to ERC 2025

Hypotension after ROSC should be avoided. The targets are systolic > 100 mmHg or MAP > 60–65 mmHg [3]. Depending on the individual situation, a higher target may be appropriate.

Therapeutic options according to ERC 2025 include:

• Fluids as required
• Noradrenaline as vasopressor
• Dobutamine in low cardiac output
• Echocardiography to assess cardiac function, volume status and possible causes

Noradrenaline infusion (example from the compendium)

Preparation: 5 mg noradrenaline in 50 ml = 0.1 mg/ml (100 µg/ml). The table shows the infusion rate in ml/h:

The dose is titrated to effect according to the target blood pressure. The current summary of product characteristics and local protocols remain authoritative.

Arrhythmias after ROSC

For recurrent or refractory arrhythmias, the following steps are recommended [3]:

• Correct electrolytes (K⁺, Mg²⁺)
• Treat ischaemia
• Use antiarrhythmic drugs or cardioversion according to the tachycardia algorithm

12-lead ECG and identifying the cause

The 12-lead ECG is one of the immediate measures after ROSC. It largely determines further management and thus also the choice of receiving hospital [3]:

Regardless of the ECG findings, the following are always required:

• Laboratory tests including electrolytes, lactate and troponin
• Echocardiography
• Systematic search for reversible causes (4 Hs and 4 Ts/HITS)

Receiving hospital: requirements arising from the care pathway

For prehospital care, this means that the receiving hospital should provide the measures that are likely to be required. Depending on the findings, these include:

• Cardiac catheterisation laboratory
• CT imaging
• Intensive care unit with temperature control using a feedback device
• EEG
• Structured, multimodal prognostication

ST elevation on the 12-lead ECG should be communicated to the receiving hospital early so that coronary angiography can be performed without delay.

Temperature management after resuscitation

In the ERC 2025 guidelines, temperature management after resuscitation clearly focuses on fever prevention [3]:

• Target: ≤ 37.5 °C in comatose patients, for at least 72 h
• Implementation: actively prevent fever, preferably using a device with temperature feedback
• Mild hypothermia (32–36 °C): do not actively rewarm
• Prehospital: no cooling with large volumes of cold intravenous fluid

For the prehospital emergency physician service, this means: existing mild hypothermia is tolerated, active warming is avoided, and temperature is measured and documented. Controlled temperature management over 72 h is the responsibility of the intensive care unit.

Further targets in the intensive care unit

• Glucose: normoglycaemia according to the unit's standard protocol; avoid hypoglycaemia.
• Seizures: treat, do not prevent. Prophylaxis is not recommended. Clinical or electrographic seizures are treated with levetiracetam or valproate, accompanied by EEG assessment. For dosing, refer to the current summary of product characteristics or guideline.
• Sedation: short-acting agents. These facilitate temperature control and subsequent neurological assessment.

Prognostication: no earlier than 72 hours

Early prognostic decisions carry the risk of a self-fulfilling prophecy. According to ERC/ESICM 2025 [3]:

• Timing: assessment not before 72 h after ROSC.
• Prerequisite: sedatives, neuromuscular blocking agents, hypothermia and metabolic derangements have been excluded as confounders.
• Method: always multimodal, using clinical examination, EEG, SSEP, biomarkers and imaging. Prognosis is never based on a single finding.
• Poor prognosis: is only assumed when at least two unfavourable findings are present. Examples include bilaterally absent pupillary and corneal reflexes ≥ 72 h or bilaterally absent N20 potentials on SSEP.
• Myoclonus with a benign EEG: awakening is still possible even after several days.

A change in treatment goals is made only after structured, multimodal assessment and discussion with the relatives. If treatment is withdrawn or brain death occurs, possible organ donation should be considered.

Follow-up and aftercare

Before discharge, ERC/ESICM 2025 recommend [3]:

• Screening for physical, cognitive and psychological sequelae
• Initiation of rehabilitation and follow-up
• Investigation of the cause, e.g. ICD indication or genetic testing in sudden cardiac death

Practice checklist: prehospital ROSC care

• ABCDE assessment, secure the airway in coma, capnography
• FiO₂ initially 100 %, then titrate to SpO₂ 94–98 %
• Aim for normocapnia, lung-protective ventilation (6–8 ml/kg predicted body weight)
• Maintain systolic > 100 mmHg or MAP > 60–65 mmHg (fluids, noradrenaline)
• Record a 12-lead ECG; if ST elevation, receiving hospital with cardiac catheterisation
• Consider reversible causes (4 Hs and 4 Ts/HITS)
• Avoid fever, do not actively rewarm mild hypothermia, no cooling with large volumes of cold intravenous fluid
• Handover including times, interventions and findings

References

• [3] Nolan JP, Sandroni C et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2025 Post-Resuscitation Care. Resuscitation 2025 / Intensive Care Med 2025;51:2213–2288.
• [1] Soar J, Böttiger BW et al. European Resuscitation Council Guidelines 2025 Adult Advanced Life Support. Resuscitation 2025;215 Suppl 1:110769 (Korrigendum 2026).
• [4] Kurzfassung der Leitlinien des European Resuscitation Council 2025. Notfall Rettungsmed 2025.

This article does not replace clinical judgement in the individual case or the current summary of product characteristics and guidelines.