SYSTEMATIC REVIEW PROTOCOL

Transcription

1 SYSTEMATIC REVIEW PROTOCOL Title of Systematic Review Protocol A systematic review of differences between brain temperature and core body temperature in adult patients with severe traumatic brain injury Centre conducting review Singapore National University Hospital (NUH) Centre for Evidence Based Nursing: A Collaborating Centre of the Joanna Briggs Institute Primary reviewer/contact Name: Kueh Wern Lunn 1 Telephone: (65) wernlunn@nus.edu.sg Secondary reviewer Name: Charmaine Childs, B Nurs, M Phil, PhD 2 Telephone: (65) Facsimile: (65) nurcc@nus.edu.sg 1 Honours Year Student, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore 2 Associate Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore. 1

2 Commencement date October 1 st Expected Completion date April 30 th

3 Review Question/Objectives The overall aim of this systematic review is to critically appraise, synthesise and present the best available evidence in relation to the absolute temperature difference between brain temperature and core body temperature in adult patients with severe traumatic brain injury. The review objective is to synthesize the best available research evidence that core body temperature is a proxy for brain temperature in adult patients with severe traumatic brain injury. This will then aid clinicians to see if core body temperature can be used as a proxy for brain temperature and thus used in the clinical setting to detect brain hyper- or hypothermia in patients with severe traumatic brain injury. Review question: What is the best available evidence that core body temperature is a proxy for brain temperature in adult patients with severe traumatic brain injury? We will look at whether brain temperature is higher, lower, or the same as core body temperature in patients with severe TBI. 3

4 Background Human body temperature, being one of the five vital signs, has been measured using various methods across the centuries. Body temperature can be defined as the difference between the amount of heat produced by body processes and the amount of heat lost to the external environment 1. Core body temperature, which is usually maintained within a relatively stable range, is regarded as the best indicator of temperature regulation in humans. 2-4 Pulmonary 2, 3, 5, 6 artery temperature is considered as the best measurement of core body temperature. Other core body temperature measurements can be made in the oesophagus, urinary bladder, rectum, or at the tympanic membrane, and from the skin overlying the temporal artery. Brain temperature monitoring has come a long way since Benzinger and colleagues 7 used the tympanum as a proxy for brain temperature monitoring. It was not until 1990 that Mellergard and colleagues 8 performed the first invasive continuous monitoring of intracranial temperature via an intraventricular thermocouple in humans. Since then, several types of invasive brain temperature monitoring have been developed to investigate the temperature in various parts of human brain. These include subdural, ventricular, and intraparenchymal sites. Despite all the emerging brain temperature measurement methods, intraventricular measurement is still considered the gold standard in providing accurate measurement of brain temperature. 9 Patients who may benefit from continuous brain temperature monitoring include patients with severe traumatic brain injury (TBI). For the purpose of this systematic review, severe TBI can be defined as a brain injury incurred by a traumatic mechanism of injury with a resultant level of consciousness categorized by a Glasgow Coma Scale (GCS) score of 8 or lower

5 TBI affects two to three million people in the United States of America (USA) each year. 11 In Singapore, one-half of trauma-related mortality are caused by TBI. 12 Road traffic accident, falls from a height, and assault are some of the factors that cause TBI. 12 Patients with severe TBI have a survival rate of 33%. 13 Of those who survive, almost all suffer prolonged hospitalization and severe disability. 12 The long-term disabilities and impairments (psychological, cognitive, sensory, and motor impairments) following severe TBI can be very serious and may persist for years. Therefore, in the long-term, the direct medical costs and indirect costs of societal loses as a result of restricted or lowered productivity are significant. 12 One of the many factors that can worsen the outcome of patient with severe TBI is raised temperature and this may be due to classical fever or to hyperthermia. Despite many guidelines in managing patients with TBI, management of raised temperature in this group of patients seemed to be left out. Studies have shown that in subarachnoid haemorrhage, intracranial haemorrhage and ischaemic stroke patients, a raise in body temperature is usually associated with a higher degree of neuronal damage and thus worsened patient outcome Similarly, in patients with TBI, raised temperature (as measured by rectal and tympanic routes) also resulted in more severe disabilities and poorer outcome 18, 19. Childs and colleagues 20 who investigated brain temperature and outcome in patients with severe TBI suggested that patients with middle range temperature in the first 48 hours of brain injury had better outcomes than in those patients with temperature at upper and lower ends of the temperature range. The cause of raised temperature in this group of patients might be due to infection, inflammation, and post-traumatic hyperthermia. However, the exact biochemical and cellular mechanisms that causes this elevation of temperature is still not fully understood 11. 5

6 There is a need to measure brain temperature accurately in patients with severe TBI. Currently in our institution, direct brain temperature monitoring is not being performed. Instead, temperature measurement from oral, axilla, tympanic membrane, and rectal routes are used as a surrogate for brain temperature. Prior to the commencement of this systematic review, the Cochrane Library and Joanna Briggs Institute (JBI) databases were searched and no previous systematic reviews on this specific topic were identified. Hence, the objective of this systematic review is to find the evidence for similarities and differences between the two measurement sites. In this way, it is hoped to close the gap in knowledge about whether core body temperature can reasonably predict brain temperature. Results from this systematic review can then enable clinicians to better understand if the methods of temperature monitoring that they are practicing now (using core body temperature as surrogate for brain temperature) can accurately reflect brain temperature. 6

7 7

8 Inclusion Criteria Types of participants The review will consider studies that include adult (more than 18 years old) male and female patients admitted into the critical care setting with the diagnosis of severe traumatic brain injury, with a Glasgow Coma Scale (GCS) of less than eight, and who require brain temperature monitoring. Exclusion Criteria This systematic review will not include the following: Publications with brain temperature monitoring performed on non-human subjects Publications that focused on other conditions like stroke, brain tumours, or other neurosurgical procedures Phenomena of interest The review will consider studies that measure brain temperature and core body temperature. Brain temperature monitoring methods that are included in this review include subdural, intraventricular and parenchymal measurements as well as jugular bulb (blood drained from the intracerebral vasculature 21 ). Core body temperature monitoring methods that will be included in this review include tympanic membrane, temporal artery, rectal, bladder, esophageal and pulmonary artery. 8

9 Types of outcomes The agreement of core body temperature as a proxy for brain temperature in adult patients with severe traumatic brain injury. Types of studies The review will consider any randomised controlled trials (RCTs). In the absence of RCTs other research designs, such as non-randomised controlled trials, before and after studies, cohort studies, and case-control studies will be considered for inclusion in a narrative summary to enable the identification of current best evidence regarding the differences between brain temperature and core body temperature in adult patients with severe traumatic brain injury. Search strategy Publications published in another language other than English will be excluded. The search strategy aims to find both published studies during the last 30 years ( ) in English language. This is because invasive brain temperature measurement was not commenced before A three-step search strategy will be utilised in each component of this review. An initial limited search of PubMed (MEDLINE) and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: 9

10 - CINAHL - PubMed (Medline) - Scopus - Web of Science - Science Direct - Ovid SP A list of initial keywords used in the search strategy can be found in Appendix I. Assessment of methodological quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II).Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data extraction Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix III). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Quantitative data will, where possible be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI- MAStARI). All results will be subject to double data entry. Odds ratio (for categorical data) 10

11 and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Potential conflict of interest No potential conflict of interest is anticipated. 11

12 References 1. Potter PA, Perry AG. Fundamentals of Nursing. Missouri: Elsevier Mosby; Hooper VD, Andrews JO. Accuracy of noninvasive core temperature measurement in acutely ill adults: the state of the science. Biol Res Nurs Jul;8(1): Giuliano KK, Scott SS, Elliot S, Giuliano AJ. Temperature measurement in critically ill orally intubated adults: a comparison of pulmonary artery core, tympanic, and oral methods. Crit Care Med Oct;27(10): Fiedler MA. Thermoregulation: anesthetic and perioperative concerns. AANA J Dec;69(6): Davie A, Amoore J. Best practice in the measurement of body temperature. Nurs Stand Jun 23-29;24(42): O'Grady NP, Barie PS, Bartlett JG, Bleck T, Carroll K, Kalil AC, et al. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med Apr;36(4): Benzinger T. Heat regulation: homeostasis of central temperature in man. Physiological Review. 1969;49(4): Mellergard PN, CH; Christensson, M. A method for monitoring intracerebral temperature in neurosurgical patients. Neurosurgery. 1990;27(4): Childs C. Human brain temperature: regulation, measurement and relationship with cerebral trauma: part 1. Br J Neurosurg Aug;22(4): [AANN] AAoNN. Nursing Management of Adults with Severe Traumatic Brain Injury. AANN Clinical Practice Guideline Series [updated September 15th, 2010]; Available from: 12

13 11. Thompson HJ, Tkacs NC, Saatman KE, Raghupathi R, McIntosh TK. Hyperthermia following traumatic brain injury: a critical evaluation. Neurobiol Dis Apr;12(3): Lee KKS, W T; Ng, I. Demographical profiles of adult severe traumatic brain injury patients: imiplications for healthcare planning. Singapore Medical Journal. 2006;47(1): Dawodu S. Traumatic Brain Injury (TBI) - Definition, Epidemiology, Pathophysiology [cited nd September]; Available from: McIlvoy L. The impact of brain temperature and core temperature on intracranial pressure and cerebral perfusion pressure. J Neurosci Nurs Dec;39(6): Hajat C, Hajat S, Sharma P. Effects of poststroke pyrexia on stroke outcome : a metaanalysis of studies in patients. Stroke Feb;31(2): Fernandez A, Schmidt JM, Claassen J, Pavlicova M, Huddleston D, Kreiter KT, et al. Fever after subarachnoid hemorrhage: risk factors and impact on outcome. Neurology Mar 27;68(13): Schwarz S, Hafner K, Aschoff A, Schwab S. Incidence and prognostic significance of fever following intracerebral hemorrhage. Neurology Jan 25;54(2): Geffroy A, Bronchard R, Merckx P, Seince PF, Faillot T, Albaladejo P, et al. Severe traumatic head injury in adults: which patients are at risk of early hyperthermia? Intensive Care Med May;30(5): Jiang JY, Gao GY, Li WP, Yu MK, Zhu C. Early indicators of prognosis in 846 cases of severe traumatic brain injury. J Neurotrauma Jul;19(7): Childs C, Vail A, Leach P, Rainey T, Protheroe R, King A. Brain temperature and outcome after severe traumatic brain injury. Neurocrit Care. 2006;5(1):

14 21. Crowder CM, Tempelhoff R, Theard MA, Cheng MA, Todorov A, Dacey RG, Jr. Jugular bulb temperature: comparison with brain surface and core temperatures in neurosurgical patients during mild hypothermia. J Neurosurg Jul;85(1):

15 Appendices Appendix I: Search terms The search terms in this systematic review can be categorized into three main concepts: Concepts Concept 1: Brain temperature Concept 2: Core body temperature Concept 3: Severe Traumatic Brain Injury Keywords Epidural Temperature Ventricular Temperature Intraparenchymal Temperature Cortical Temperature Intraventricular Temperature Jugular Bulb Temperature Subdural Temperature Brain Temperature Core Temperature Body Temperature Core Body Temperature Pulmonary Artery Temperature Esophageal Temperature Oesophageal Temperature Bladder Temperature Tympanic Temperature Temporal Artery Temperature Rectal Temperature Severe Traumatic Brain Injury Traumatic Brain Injury TBI Brain Injury Head Injury 15

16 Using the search terms above in the different databases, the following search strategies are obtained: Database: CINAHL Search Keywords 1 ( Brain Temperature ) AND ( Core Temperature ) 2 ( Brain Temperature ) AND ( Core Temperature ) AND ( Brain Injur* ) ("Epidural Temperature") OR ("Ventricular Temperature") OR ("Intraparenchymal Temperature") OR ("Cortical Temperature") OR 3 ("Intraventricular Temperature") OR ("Jugular Bulb Temperature") OR ("Subdural Temperature") OR ("Brain Temperature") ( Core Temperature ) OR ( Body Temperature ) OR ( Core Body Temperature ) OR ( Pulmonary Artery Temperature ) OR ( Esophageal Temperature ) OR ( Oesophageal Temperature ) OR ( Bladder Temperature ) OR ( Tympanic Temperature ) OR ( Temporal Artery Temperature ) OR 4 ( Rectal Temperature ) OR (MH "Core Body Temperature") OR (MH "Rectal Body Temperature") OR (MH "Tympanic Body Temperature") OR (MM "Core Body Temperature") OR (MM "Rectal Body Temperature") OR (MM "Tympanic Body Temperature") OR (MH "Body Temperature+") ( Severe Traumatic Brain Injur* ) OR ( Traumatic Brain Injur* ) OR ( TBI ) 5 OR ("Brain Injur*") OR (MM Head Injuries+ ) OR (MH Head Injuries+ ) OR (MM "Brain Injuries+") OR (MH "Brain Injuries+") 6 S3 AND S4 7 S3 AND S4 AND S5 16

17 Database: PubMed (MEDLINE) Search Keywords 1 "Brain Temperature"[All Fields] AND "Core Temperature"[All Fields] "Brain Temperature"[All Fields] AND "Core Temperature"[All Fields] AND 2 (brain injur*[all Fields]) "Epidural Temperature"[All Fields] OR "Ventricular Temperature"[All Fields] OR "Intraparenchymal Temperature"[All Fields] OR "Cortical Temperature"[All 3 Fields] OR "Intraventricular Temperature"[All Fields] OR "Jugular Bulb Temperature"[All Fields] OR "Subdural Temperature"[All Fields] OR "Brain Temperature"[All Fields] "Core Temperature"[All Fields] OR "Body Temperature"[All Fields] OR "Core Body Temperature"[All Fields] OR "Pulmonary Artery Temperature"[All Fields] OR "Esophageal Temperature"[All Fields] OR "Oesophageal 4 Temperature"[All Fields] OR "Bladder Temperature"[All Fields] OR "Tympanic Temperature"[All Fields] OR "Temporal Artery Temperature"[All Fields] OR "Rectal Temperature"[All Fields] OR "Body Temperature"[MeSH Major Topic] OR "Body Temperature"[Mesh] (Severe Traumatic Brain Injur*[All Fields]) OR (Traumatic Brain Injur*[All Fields]) OR TBI [All Fields] OR (Brain Injur*[All Fields]) OR "Craniocerebral Trauma"[Mesh] OR "Craniocerebral Trauma"[MeSH Major Topic] OR "Head 5 Injuries, Closed"[Mesh] OR "Head Injuries, Closed"[MeSH Major Topic] OR "Head Injuries, Penetrating"[Mesh] OR "Head Injuries, Penetrating"[MeSH Major Topic] OR "Brain Injuries"[Mesh] OR "Brain Injuries"[MeSH Major Topic] 6 #3 AND #4 7 #3 AND #4 AND #5 17

18 Database: Scopus Search Keywords 1 ALL(("brain temperature" AND "core temperature")) 2 ALL(( brain temperature ) AND ( core temperature ) AND ( brain injur* )) ((TITLE-ABS-KEY((( Core Temperature ) OR ( Body Temperature ) OR ( Core Body Temperature ) OR ( Pulmonary Artery Temperature ) OR ( Esophageal Temperature ) OR ( Oesophageal Temperature ) OR ( Bladder Temperature ) OR ( Tympanic Temperature ) OR ( Temporal Artery 3 Temperature ) OR ( Rectal Temperature )))) AND (((ALL(("Epidural Temperature") OR ("Ventricular Temperature") OR ("Intraparenchymal Temperature") OR ("Cortical Temperature") OR ("Intraventricular Temperature") OR ("Jugular Bulb Temperature") OR ("Subdural Temperature") OR ("Brain Temperature"))) (TITLE-ABS-KEY((("Epidural Temperature") OR ("Ventricular Temperature") OR ("Intraparenchymal Temperature") OR ("Cortical Temperature") OR ("Intraventricular Temperature") OR ("Jugular Bulb Temperature") OR ("Subdural Temperature") OR ("Brain Temperature")))) AND 4 (ALL(( Core Temperature ) OR ( Body Temperature ) OR ( Core Body Temperature ) OR ( Pulmonary Artery Temperature ) OR ( Esophageal Temperature ) OR ( Oesophageal Temperature ) OR ( Bladder Temperature ) OR ( Tympanic Temperature ) OR ( Temporal Artery Temperature ) OR ( Rectal Temperature )))) (TITLE-ABS-KEY((( Severe Traumatic Brain Injur* ) OR ( Traumatic Brain Injur* ) OR ( TBI ) OR ("Brain Injur*") OR (Head Injur*))))) AND 5 (ALL((( Severe Traumatic Brain Injur* ) OR ( Traumatic Brain Injur* ) OR ( TBI ) OR ("Brain Injur*") OR ( Head Injur*))))) ((TITLE-ABS-KEY((( Core Temperature ) OR ( Body Temperature ) OR ( Core Body Temperature ) OR ( Pulmonary Artery Temperature ) OR ( Esophageal Temperature ) OR ( Oesophageal Temperature ) OR ( Bladder 6 Temperature ) OR ( Tympanic Temperature ) OR ( Temporal Artery Temperature ) OR ( Rectal Temperature )))) AND (TITLE-ABS-KEY((("Epidural Temperature") OR ("Ventricular Temperature") 18

19 OR ("Intraparenchymal Temperature") OR ("Cortical Temperature") OR ("Intraventricular Temperature") OR ("Jugular Bulb Temperature") OR ("Subdural Temperature") OR ("Brain Temperature")))) AND (TITLE-ABS-KEY((( Severe Traumatic Brain Injur* ) OR ( Traumatic Brain Injur* ) OR ( TBI ) OR ("Brain Injur*") OR (Head Injur*))))) AND (((ALL(("Epidural Temperature") OR ("Ventricular Temperature") OR ("Intraparenchymal Temperature") OR ("Cortical Temperature") OR ("Intraventricular Temperature") OR ("Jugular Bulb Temperature") OR ("Subdural Temperature") OR ("Brain Temperature"))) AND (ALL(( Core Temperature ) OR ( Body Temperature ) OR ( Core Body Temperature ) OR ( Pulmonary Artery Temperature ) OR ( Esophageal Temperature ) OR ( Oesophageal Temperature ) OR ( Bladder Temperature ) OR ( Tympanic Temperature ) OR ( Temporal Artery Temperature ) OR ( Rectal Temperature )))) AND (ALL((( Severe Traumatic Brain Injur* ) OR ( Traumatic Brain Injur* ) OR ( TBI ) OR ("Brain Injur*") OR ( Head Injur*))))) 19

20 Database: Web of Science Search Keywords Topic=("Brain Temperature" or "Core Temperature") OR 1 Title=("Brain Temperature" or "Core Temperature") Topic=("Brain Temperature" or "Core Temperature" or "Brain Injur*") OR 2 Title=("Brain Temperature" or "Core Temperature" or "Brain Injur*") Topic=("Epidural Temperature" or "Ventricular Temperature" or "Intraparenchymal Temperature" or "Cortical Temperature" or "Intraventricular Temperature" or "Jugular Bulb Temperature" or "Subdural Temperature" or "Brain Temperature") OR 3 Title=("Epidural Temperature" or "Ventricular Temperature" or "Intraparenchymal Temperature" or "Cortical Temperature" or "Intraventricular Temperature" or "Jugular Bulb Temperature" or "Subdural Temperature" or "Brain Temperature") Topic=("Core Temperature" or "Body Temperature" or "Core Body Temperature" or "Rectal Temperature" or "Bladder Temperature" or "Esophageal Temperature" or "Oesophageal Temperature" or "Pulmonary Artery Temperature" or "Tympanic Temperature" or "Temporal Artery Temperature") 4 OR Title=("Core Temperature" or "Body Temperature" or "Core Body Temperature" or "Rectal Temperature" or "Bladder Temperature" or "Esophageal Temperature" or "Oesophageal Temperature" or "Pulmonary Artery Temperature" or "Tympanic Temperature" or "Temporal Artery Temperature") Topic=("Severe Traumatic Brain Injur*" or "Traumatic Brain Injur*" or "TBI" or "Brain Injur*" or "Head Injur*") OR 5 Title=("Severe Traumatic Brain Injur*" or "Traumatic Brain Injur*" or "TBI" or "Brain Injur*" or "Head Injur*") 6 #3 AND #4 7 #3 AND #4 AND #5 20

21 Database: Science Direct Search Keywords 1 ALL(( Brain Temperature ) AND ( Core Temperature )) ALL(( Brain Temperature ) AND ( Core Temperature ) AND ( Brain 2 Injur* )) ALL(("Epidural Temperature") OR ("Ventricular Temperature") OR ("Intraparenchymal Temperature") OR ("Cortical Temperature") OR 3 ("Intraventricular Temperature") OR ("Jugular Bulb Temperature") OR ("Subdural Temperature") OR ("Brain Temperature")) ALL(( Core Temperature ) OR ( Body Temperature ) OR ( Core Body Temperature ) OR ( Pulmonary Artery Temperature ) OR ( Esophageal 4 Temperature ) OR ( Oesophageal Temperature ) OR ( Bladder Temperature ) OR ( Tympanic Temperature ) OR ( Temporal Artery Temperature ) OR ( Rectal Temperature )) ALL(( Severe Traumatic Brain Injur* ) OR ( Traumatic Brain Injur* ) 5 OR ( TBI ) OR ("Brain Injur*") OR ("Head Injur*")) ALL(("Epidural Temperature") OR ("Ventricular Temperature") OR ("Intraparenchymal Temperature") OR ("Cortical Temperature") OR ("Intraventricular Temperature") OR ("Jugular Bulb Temperature") OR ("Subdural Temperature") OR ("Brain Temperature")) AND ALL(( Core Temperature ) OR ( Body Temperature ) OR ( Core Body 6 Temperature ) OR ( Pulmonary Artery Temperature ) OR ( Esophageal Temperature ) OR ( Oesophageal Temperature ) OR ( Bladder Temperature ) OR ( Tympanic Temperature ) OR ( Temporal Artery Temperature ) OR ( Rectal Temperature )) AND ALL(( Severe Traumatic Brain Injur* ) OR ( Traumatic Brain Injur* ) OR ( TBI ) OR ("Brain Injur*") OR ("Head Injur*")) 21

22 Database: Ovid SP Search Keywords 1 (Brain Temperature) AND (Core Temperature) 2 (Brain Temperature) AND (Core Temperature) AND (Brain Injury) {} (Epidural Temperature) OR (Ventricular Temperature) OR (Intraparenchymal Temperature) OR (Cortical Temperature) OR (Intraventricular Temperature) OR 3 (Jugular Bulb Temperature) OR (Subdural Temperature) OR (Brain Temperature) (Core Temperature) OR (Body Temperature) OR (Core Body Temperature) OR (Pulmonary Artery Temperature) OR (Esophageal Temperature) OR 4 (Oesophageal Temperature) OR (Bladder Temperature) OR (Tympanic Temperature) OR (Temporal Artery Temperature) OR (Rectal Temperature) (Severe Traumatic Brain Injury) OR (Traumatic Brain Injury) OR (TBI) OR 5 (Brain Injury) OR (Head Injury) ((Epidural Temperature) OR (Ventricular Temperature) OR (Intraparenchymal Temperature) OR (Cortical Temperature) OR (Intraventricular Temperature) OR (Jugular Bulb Temperature) OR (Subdural Temperature) OR (Brain Temperature)) AND ((Core Temperature) OR (Body Temperature) OR (Core 6 Body Temperature) OR (Pulmonary Artery Temperature) OR (Esophageal Temperature) OR (Oesophageal Temperature) OR (Bladder Temperature) OR (Tympanic Temperature) OR (Temporal Artery Temperature) OR (Rectal Temperature)) AND ((Severe Traumatic Brain Injury) OR (Traumatic Brain Injury) OR (TBI) OR (Brain Injury) OR (Head Injury)) 22

23 Appendix II: Joanna Briggs Institute Critical appraisal Instruments 23

24 24

25 Appendix III: Joanna Briggs Institute Data Extraction Instrument 25

26 26