Japanese Society of Anesthesiology Hemodynamic Monitoring Questionnaire

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:

1. Cardiac or respiratory illness resulting in functional limitation
2. Extensive surgery planned for carcinoma involving bowel anastomosis
3. Predictable acute massive blood loss (2.5 liters)
4. Aged over 70 years with functional limitation of one or more organ systems
5. Septicemia
6. Respiratory failure (PaO2/FiO2ratio 150 mmHg or ventilation 48 hours)
7. Acute abdomen (e.g. pancreatitis, perforated bowel, gastro-intestinal bleed)
8. Acute renal failure (urea 56mg/dL, creatinine 2.94mg/dL)
9. Surgery for abdominal aortic aneurysm
10. Disseminated malignancy

Questionnaire

1. 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.

1. 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

1. Which statement best describes your practice setting?

□University Hospital

□General Hospital

□Private Practice

□Other

Other (please specify)

1. Does your institution or group perform an Enhanced Recovery After Surgery (ERAS) protocol in your routine practice?

□Yes

□No

□Unsure or don’t know

1. 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

1. 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

1. 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

1. 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

1. 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

1. 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

1. 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

1. 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

1. 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

1. When do you think that hemodynamic optimization is of most value?

□Before anesthesia induction

□After anesthesia induction

□During surgery

□In the postoperative period

1. 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:

1. 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)

1. 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

1. 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

1. 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)

1. 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

1. What is your first choice solution for volume expansion?

□Crystalloids

□Hydroxyethyl starch solutions

□Human albumin

□Blood derived products

□Dextrans

1. Do you or your department/group manage these patients in the intensive care unit?

□Yes

□No

1. If not, who manages these patients in the ICU?

□Critical Care physicians

□Surgeons

□Physicians

□Other anesthesiologists

□Mixed population

1. Do you believe that oxygen delivery to the tissues is of major importance in patients during high risk surgery?

□Yes

□No

1. What parameter(s) is (are) involved in oxygen delivery to the tissues?

□Arterial Pressure

□Cardiac Output

□Central venous pressure

□PaO2

□SaO2

□Hemoglobin

1. Do you believe that your current hemodynamic management could be improved?

□Yes

□No

1. 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

1. What is your license as an anesthesiologists

□None

□Japanese Society of Anesthesiologist (JSA) Qualified Anesthesiologist

□JSA Board Certified Anesthesiologist

□Fellow of JSA

1. What is your sub-specialty area?

□None

□Cardiac anesthesia

□Pediatric anesthesia

□Obstetric anesthesia

□Critical care

□Emergency medicine

□Pain clinic

□Others

1. Where is your institution (please specify the prefecture)?

1. How many anesthesiologists (Total, JSA Qualified Anesthesiologist, JSA Board Certified Anesthesiologist and Fellow of JSA) do you have in your institution?

1. 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

1. 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

1. 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

1. 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

JSA: Japanese Society of Anesthesiologists

Appendix 3. Device for cardiac output monitoring among Japanese Society of Anesthesiologists respondents

JSA: Japanese Society of Anesthesiologists

Appendix 4. Reasons for notmonitoring cardiac output

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

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

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

JSA: Japanese Society of Anesthesiologists, LVEDV: left ventricular end-diastolic volume, SPV: Systolic pressure variation, PPV: Pulse pressure variation