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/FiO2 ratio < 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.

2. 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

3. Which statement best describes your practice setting?

□ University Hospital

□ General Hospital

□ Private Practice

□ Other

Other (please specify)

4. Does your institution or group perform an Enhanced Recovery After Surgery (ERAS) protocol in your

routine practice?

□ Yes

□ No

□ Unsure or don’t know

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. How frequently do you try to optimize (maintain these parameters within certain range) dynamic

parameters of fluid responsiveness (Pulse Pressure Variations, Systolic Pressure Variations, 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

13. 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

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

□ Before anesthesia induction

□ After anesthesia induction

□ During surgery

□ In the postoperative period

15. 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:

16. 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)

17. If you do not monitor cardiac output routinely in these patients, what are the main reasons for not

monitoring it? (please, mark all that 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

18. 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

19. 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)

20. 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

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

□ Crystalloids

□ Hydroxyethyl starch solutions

□ Human albumin

□ Blood derived products

□ Dextrans

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

□ Yes

□ No

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

□ Critical Care physicians

□ Surgeons

□ Physicians

□ Other anesthesiologists

□ Mixed population

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

surgery?

□ Yes

□ No

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

□ Arterial Pressure

□ Cardiac Output

□ Central venous pressure

□ PaO2

□ SaO2

□ Hemoglobin

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

□ Yes

□ No

27. 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

28. What is your license as an anesthesiologists

□ None

□ Japanese Society of Anesthesiologist (JSA) Qualified Anesthesiologist

□ JSA Board Certified Anesthesiologist

□ Fellow of JSA

29. What is your sub-specialty area?

□ None

□ Cardiac anesthesia

□ Pediatric anesthesia

□ Obstetric anesthesia

□ Critical care

□ Emergency medicine

□ Pain clinic

□ Others

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

31. How many anesthesiologists (Total, JSA Qualified Anesthesiologist, JSA Board Certified

Anesthesiologist and Fellow of JSA) do you have in your institution?

32. How many operating rooms does your primary hospital have?

□ Less than 4 rooms

□ 4 to 6 rooms

□ 7 to 10 rooms

□ 11 to 15 rooms

□ 16 to 20 rooms

□ More than 20 rooms

33. 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

34. 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

35. 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 pressure variation 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 not monitoring 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