Appendix 1.
Japanese Society of Anesthesiology Hemodynamic Monitoring Questionnaire
Hemodynamic management in patients undergoing high-risk surgery
For the following questionnaire, we will define high risk surgery patients as patients aged 18 years or older presenting for major non-cardiac surgery expected to last more than 1.5 hours and having at least two of the following criteria:
- Cardiac or respiratory illness resulting in functional limitation
- Extensive surgery planned for carcinoma involving bowel anastomosis
- Predictable acute massive blood loss (2.5 liters)
- Aged over 70 years with functional limitation of one or more organ systems
- Septicemia
- Respiratory failure (PaO2/FiO2ratio 150 mmHg or ventilation 48 hours)
- Acute abdomen (e.g. pancreatitis, perforated bowel, gastro-intestinal bleed)
- Acute renal failure (urea 56mg/dL, creatinine 2.94mg/dL)
- Surgery for abdominal aortic aneurysm
- Disseminated malignancy
Questionnaire
- In your routine practice, do you provide or directly supervise anesthesia for this type of patient?
□I do not provide or directly supervise anesthesia for this type of patient.
□I provide or directly supervise anesthesia for this type of patient.
- How many times in a typical work week do you provide or directly supervise anesthesia for a high risk surgery patient?
□Rarely or Never
□1 to 5 times a week
□6 to 10 times a week
□More than 11 times a week
- Which statement best describes your practice setting?
□University Hospital
□General Hospital
□Private Practice
□Other
Other (please specify)
- Does your institution or group perform an Enhanced Recovery After Surgery (ERAS) protocol in your routine practice?
□Yes
□No
□Unsure or don’t know
- Does your institution or group have a written protocol, care guide, or statement concerning hemodynamic management (goal-directed therapy) in this setting?
□Yes
□No
□Unsure or don’t know
- What hemodynamic monitoring do you routinely use for the management of high risk surgery patients? (please, mark all that apply)
□Non-invasive arterial pressure
□Invasive arterial pressure
□Cardiac output
□Central venous pressure
□Pulmonary capillary wedge pressure
□Mixed venous oxygen saturation
□Central venous oxygen saturation
□Oxygen delivery
□Pleth variability index
□Stroke volume variation
□Systolic pressure variation
□Pulse pressure variation
□Global end diastolic volume
□Near infrared spectroscopy
□Transesophageal echocardiography
- How frequently do you try to optimize arterial pressure (maintain these parameters within certain range) intraoperatively in this setting?
□Never
□Less than 5 percent of the time
□Between 6 and 25 percent of the time
□Between 26 and 50 percent of the time
□Between 51 and 75 percent of the time
□More than 75 percent of the time
- How frequently do you try to optimize central venous pressure (maintain these parameters within certain range) in this setting?
□Never
□Less than 5 percent of the time
□Between 6 and 25 percent of the time
□Between 26 and 50 percent of the time
□Between 51 and 75 percent of the time
□More than 75 percent of the time
- How frequently do you try to optimize (give fluid bolus or inotropic agents until cardiac output does not significantly increase) cardiac output in this setting?
□Never
□Less than 5 percent of the time
□Between 6 and 25 percent of the time
□Between 26 and 50 percent of the time
□Between 51 and 75 percent of the time
□More than 75 percent of the time
- How frequently do you try to optimize (maintain these parameters within certain range) central venous oxygen saturation (ScvO2) in this setting?
□Never
□Less than 5 percent of the time
□Between 6 and 25 percent of the time
□Between 26 and 50 percent of the time
□Between 51 and 75 percent of the time
□More than 75 percent of the time
- How frequently do you try to optimize (maintain these parameters within certain range) mixed venous oxygen saturation (SvO2) in this setting?
□Never
□Less than 5 percent of the time
□Between 6 and 25 percent of the time
□Between 26 and 50 percent of the time
□Between 51 and 75 percent of the time
□More than 75 percent of the time
- How frequently do you try to optimize (maintain these parameters within certain range) dynamic parameters of fluid responsiveness (Pulse Pressure Variations, Systolic PressureVariations, Pleth Variability Index) in this setting?
□Never
□Less than 5 percent of the time
□Between 6 and 25 percent of the time
□Between 26 and 50 percent of the time
□Between 51 and 75 percent of the time
□More than 75 percent of the time
- If you optimize hemodynamics in your high risk surgery patients, when do you do it?
□Before anesthesia induction
□After anesthesia induction
□During surgery
□In the postoperative period
- When do you think that hemodynamic optimization is of most value?
□Before anesthesia induction
□After anesthesia induction
□During surgery
□In the postoperative period
- Regarding respiratory variations in arterial pulse and/or systolic pressure: how do you measure these indices in the clinical setting?
□Eyeballing
□Manual calculation
□Automatic measurement using specific software
If you use automatic measurement using a dedicated software, please specify which one:
- What technique do you use to monitor cardiac output? (please, mark all that apply)
□Do not monitor cardiac output
□Pulmonary artery catheter
□Vigileo-FloTrac monitor
□EV – 1000 monitor
□PiCCO Monitor
□LiDCO Monitor
□Esophageal Doppler
□Transesophageal echocardiography
□Thoracic bioimpedance
□Other (please specify)
- If you do not monitor cardiac output routinely in these patients, what are the main reasons for not monitoring it? (please, mark allthat apply)
□I use SvO2 and/or ScvO2 as surrogates for cardiac output monitoring
□Cardiac output monitoring does not provide any additional clinically relevant information in this setting
□I use dynamic parameters of fluid responsiveness (Pulse Pressure Variations, Systolic Pressure Variations, Pleth Variability Index) as surrogates for cardiac output monitoring
□Available cardiac output monitoring solutions are too invasive
□Available cardiac output monitoring solutions are unreliable
- What are your indicators for volume expansion in this setting (diagnostic tools)? (please, mark all that apply)
□Urine output
□Blood pressure
□Cardiac output
□Central venous pressure
□Pulmonary capillary wedge pressure
□Stroke Volume Variation
□Pulse Pressure Variation or Systolic Pressure Variation
□Pleth Variability Index
□Mixed venous saturation (SvO2)
□Central venous saturation (ScvO2)
□Global end diastolic volume
□Transesophageal echocardiography
□Clinical experience
- How do you routinely assess the hemodynamic effects of volume expansion in this setting?
□Increase in blood pressure
□Decrease in heart rate
□Increase in urine output
□Increase in cardiac output
□Decrease in stroke volume variation
□Decrease in pulse pressure variation or systolic pressure variation
□Decrease in pleth variability index
□Increase in mixed venous saturation (SvO2)
□Increase in central venous saturation (ScvO2)
- In your opinion, what best predicts an increase in cardiac output following volume expansion?
□Blood pressure
□Cardiac output
□Central venous pressure
□Pulmonary capillary wedge pressure
□Stroke Volume Variation
□Pulse Pressure Variation or Systolic Pressure Variation
□Pleth Variability Index
□Mixed venous saturation (SvO2)
□Central venous saturation (ScvO2)
□Global end diastolic volume
□Transesophageal echocardiography
□Clinical experience
- What is your first choice solution for volume expansion?
□Crystalloids
□Hydroxyethyl starch solutions
□Human albumin
□Blood derived products
□Dextrans
- Do you or your department/group manage these patients in the intensive care unit?
□Yes
□No
- If not, who manages these patients in the ICU?
□Critical Care physicians
□Surgeons
□Physicians
□Other anesthesiologists
□Mixed population
- Do you believe that oxygen delivery to the tissues is of major importance in patients during high risk surgery?
□Yes
□No
- What parameter(s) is (are) involved in oxygen delivery to the tissues?
□Arterial Pressure
□Cardiac Output
□Central venous pressure
□PaO2
□SaO2
□Hemoglobin
- Do you believe that your current hemodynamic management could be improved?
□Yes
□No
- How many years have you worked as a doctor
□Less than 3 years
□3 to 4 years
□5 to 7 years
□8 to 10 years
□11 to 15 years
□16 to 20 years
□More than 20 years
- What is your license as an anesthesiologists
□None
□Japanese Society of Anesthesiologist (JSA) Qualified Anesthesiologist
□JSA Board Certified Anesthesiologist
□Fellow of JSA
- What is your sub-specialty area?
□None
□Cardiac anesthesia
□Pediatric anesthesia
□Obstetric anesthesia
□Critical care
□Emergency medicine
□Pain clinic
□Others
- Where is your institution (please specify the prefecture)?
- How many anesthesiologists (Total, JSA Qualified Anesthesiologist, JSA Board Certified Anesthesiologist and Fellow of JSA) do you have in your institution?
- How many operating rooms does your primary hospital have?
□Less than 4 rooms
□4 to 6rooms
□7 to 10rooms
□11 to 15rooms
□16 to 20rooms
□More than 20rooms
- How many anesthetic cases does your group manage per year?
□Less than 500 cases
□501 to 1000 cases
□1001 to 2000 cases
□2001 to 3000 cases
□3001 to 4000 cases
□4001 to 5000 cases
□More than 5000 cases
- How many intensive care unit beds does your primary hospital have?
□0 bed
□1 to 3 beds
□4 to 6 beds
□7 to 10 beds
□11 to 20 beds
□More than 20 beds
- How many beds does your primary hospital have?
□100 or less beds
□101 to 250 beds
□251 to 500 beds
□501 to 1,000 beds
□More than 1,000 beds
Thank you so much for taking time to answer these questions.
Appendix 2. Monitored parameters for high risk surgery patients
Variables / JSA respondents(n = 548)
Invasive arterial pressure / 98.7%
Non-invasive arterial pressure / 76.1%
Stroke volume variation / 73.9%
Cardiac output / 69.9%
Central venous pressure / 60.0%
Central venous oxygen saturation / 32.7%
Transesophageal echocardiography / 32.5%
Mixed venous oxygen saturation / 21.0%
Pulse pressurevariation / 16.1%
Pulmonary capillary wedge pressure / 15.0%
Pleth variability index / 12.0%
Near infrared spectroscopy / 9.9%
Systolic pressure variation / 9.5%
Oxygen delivery / 4.6%
Global end diastolic volume / 2.6%
JSA: Japanese Society of Anesthesiologists
Appendix 3. Device for cardiac output monitoring among Japanese Society of Anesthesiologists respondents
Answer options / JSA respondents(n = 548)
Vigileo-FloTrac monitor / 81.2%
Pulmonary artery catheter / 25.4%
Transesophageal echocardiography / 25.4%
EV 1000 monitor / 18.4%
Esophageal Doppler / 2.6%
LiDCO monitor / 1.8%
PiCCO monitor / 1.5%
Thoracic bioimpedance / 0.4%
Other / 1.1%
None / 13.7%
JSA: Japanese Society of Anesthesiologists
Appendix 4. Reasons for notmonitoring cardiac output
Answer options / JSA respondents(n = 93)
Available hemodynamic monitor solutions are too invasive / 31.2%
I use dynamic parameters of fluid responsiveness (SVV, PPV, SPV and PVI) as surrogates for cardiac output monitoring / 25.8%
Available cardiac output monitoring solutions are unreliable / 22.6%
Cardiac output monitoring does not provide any additional clinically relevant information in this setting / 21.5%
I use ScvO2 or SvO2 as surrogates for cardiac output monitoring / 4.3%
JSA: Japanese Society of Anesthesiologists, SVV: Stroke volume variation, PPV: Pulse pressure variation, SPV: Systolic pressure variation, PPV: Pulse pressure variation
Appendix 5. Indicators for fluid loading in high risk surgery patients
Variables / JSA respondents(n = 548)
Blood pressure / 89.2%
Urine output / 80.1%
Stroke volume variation / 75.6%*
Cardiac output / 56.4%
Central venous pressure / 47.8%**
Clinical experience / 46.2%**
LVEDV by Transesophageal echocardiography / 29.9%
SPV or PPV / 24.6%
Central venous oxygen saturation / 19.5%
Pulmonary capillary wedge pressure / 15.3%
Mixed venous oxygen saturation / 13.7%
Pleth variability index / 8.6%
Global end diastolic volume / 3.7%
JSA: Japanese Society of Anesthesiologists, LVEDV: left ventricular end-diastolic volume, SPV: Systolic pressure variation, PPV: Pulse pressure variation
Appendix 6. How to assess the hemodynamic effects of fluid loading
Variables / JSA respondents(n = 548)
Increase in blood pressure / 84.9%
Decrease in stroke volume variation / 77.4%
Increase in urine output / 76.6%
Decrease in heart rate / 75.4%
Increase in cardiac output / 60.2%
Decrease in SPV or PPV / 24.5%
Increase in ScvO2 / 18.4%
Increase in SvO2 / 13.5%
Decrease in pleth variability index / 9.1%
JSA: Japanese Society of Anesthesiologists, SPV: Systolic pressure variation, PPV: Pulse pressure variation
Appendix 7. Predictors for an increase in cardiac output after fluid loading in high risk surgery patients
Variables / JSA respondents(n = 548)
Stroke volume variation / 31.6%
Cardiac output / 21.7%
Blood pressure / 13.7%
LVEDV by Transesophageal echocardiography / 11.0%
Clinical experience / 8.9%
SPV or PPV / 6.0%
Mixed venous oxygen saturation / 2.9%
Central venous pressure / 1.3%
Pulmonary capillary wedge pressure / 1.1%
Central venous oxygen saturation / 0.9%
Global end diastolic volume / 0.6%
Pleth variability index / 0.4%
JSA: Japanese Society of Anesthesiologists, LVEDV: left ventricular end-diastolic volume, SPV: Systolic pressure variation, PPV: Pulse pressure variation