Jpn J Extra-Corporeal Technology 39（2）：113 − 119, 2012

あ A survey of the present status of perfusion in institutions withmembers of the Japanese Society of Extra-Corporeal Technology in
Medicine：Toward development of a perfusion database あ
Makoto Hibiya 1），Tetsuya Kamei 1），Kiyoshi Yoshida 2），Koji Takai 3）
Tomohiro Nakamura 4），Hiroya Kano 5），Shoji Kubota 6），Kyoichi Kemmoku 7）

Abstract
To construct a perfusion database in Japan by modifying the input parameters of the adult perfusion registryof the International Consortium for Evidence-based Perfusion (ICEBP) to suit the present status of Japan, wesurveyed basic information on perfusion using a questionnaire consisting of 108 questions (basic survey items anditems regarding the practice of perfusion) in 557 institutions to which regular members of the Japanese Societyof Extra-Corporeal Technology in Medicine (JaSECT) were affiliated.
The questionnaire recovery rate was 48%. Access to the Internet was possible in 87% of the responder institutions.
As applications for data processing, 81% possessed MS-Excel, and 51% possessed FileMaker. Concerning circuits,
handwriting was used for perfusion recording for 53% of circuits, and selective cerebral perfusion was used for
35%. A crystalloid priming solution was used for 87%.
The number of perfusion cases in these institutions accounted for 74% of that of registered cases during thisyear in the Japan Adult Cardiovascular Surgery Database (JACVSD). If all institutions where JaSECT members
work participate in the perfusion case registration project, the number of registered cases will steadily increase,and a sufficient statistical power will be achieved early.
This survey suggested that the database parameters used by the ICEBP can be used commonly in Japan. In
addition, based on the results of the open heart surgery cases in Japan, almost equal numbers of perfusion casesof coronary heart diseases, those of valve disease, and those of aortic diseases can be registered, which allows
globally valuable characteristic epidemiological evaluation.
Key words：survey，questionnaire，cardiopulmonary bypass，database

Ⅰ．Introduction

reviews of scientific studies and case reports according

In recent years, evidence-based medicine (EBM)

to the classification of recommendations and level ofhas been established, and this term has been spread­evidence 1) by the ACC/AHA 2, 3).

ing to the general public. In the perfusion field, theWhether or not these evaluations are beneficial toterm evidence-based perfusion (EBP) is globally

patients can be determined through re-evaluation

spreading. Part of the evidence on perfusion and its

by clinical epidemiological studies performed after

technology has been provided by the evaluation oflarge-scale, long-term domestic or international perfu­

1）Fujita Health University, School of Health Science2）Osaka Rosai Hospital3）Nagoya Medical Center4）Nagoya University Hospital5）Kobe University Hospital
6）Asahikawa City Hospital
7）Saitama Medical University

Corresponding Author：Makoto Hibiya
Fujita Health University, School of Health
Science
1-98, Dengakugakubo, Kutsukake-cho, Toyoake,
Aichi, 470-1192, Japan.
［Received March 16, 2012：Accepted May 21, 2012］

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sion case registration. In addition, new evidence is

can facilitate international statistical comparison isprovided by perfusion case registration, and the re-necessary.
To construct a perfusion database in which theevaluated and new evidence is published as guidelines

input parameters of ICEBP’s adult perfusion registry

providing common parameters.
In the perfusion technology field, such an attempt

are adjusted to the present status in Japan, we

was started by the American Society of Extra-Co­

performed a survey on basic information on perfusion

rporeal Technology (AmSECT), who organized thepractice in each institution.

International Consortium for Evidence-Based Perfu­
sion (ICEBP), recognizing the importance of the dev­

Ⅱ．Methods

elopment of guidelines and a case registry project 4).

We performed a survey of 557 institutions to which

The ICEBP announced the launch of a project toregular JaSECT members are affiliated. In eachpromote an international perfusion case registry,

institution, 1 member was randomly selected, andand initiated registration as a trial in Michigan ina request for the survey was sent to this member

cooperation with the Michigan Society of Thoracic

by mail. An MS-Excel (Microsoft, WA, USA) file as

and Cardiovascular Surgeons 5).

a questionnaire was voluntarily downloaded by this

The Japanese Society of Extra-Corporeal Techno­member using the Internet from the server installed

logy in Medicine (JaSECT) participated in the ICEBP

in Fujita Health University. Answers to questionsin 2006, and initiated a project in 2008 to develop

were inputted, and the file was attached to an e-mail,perfusion guidelines in Japan in the future. The

and collected. The collection of the questionnaire waspurpose of this project is to realize the early provision

regarded as consent to the survey.

of objective evidence to which clinical epidemiology

The questionnaire items included the environmentis introduced, and contribute to improvement infor the use of the database and the number of perfu­

treatment results by providing appropriate technicalsion cases as basic items, the constitution of generally

support.

used circuits, drug and examination parameters

The ICEBP and Perfusion Downunder in Australia,

as parameters related to the practice of perfusion,and the Belgian Society for Extra-Corporeal Circula­and the composition of the priming solution. Theretion Technology (BelSECT) initiated the use (including

were 108 questionnaire items, which consisted of 59

trial use) of a perfusion database. To conduct perfu­

single-answer questions, 3 multiple-answer questions,sion registration in Japan, following these organiza­

15 free-answer questions, and 31 numeric-answer

tions, the JaSECT performed present status surveys

questions.

6, 7)

The survey period was from January 11 to Marchin Japan, the U.S., and Australia .
8)

Based on the results of these surveys, we paid

31, 2011. This survey was performed with the support

atten­tion to cases in which the use of the open heartof the Japanese Association for Thoracic Surgery

surgery database by cardiovascular surgeons was

and Japanese Society for Cardiovascular Surgery andsuccessful. In Japan, the Japanese Association forwith the approval of the Ethics Committee for ClinicalThoracic Surgery and Japanese Society for Cardio­

Research of Fujita Health University (notification No.

vascular Surgery jointly organized the Japan Adult

10-173).

Cardiovascular Surgery Database (JACVSD) System,
and use the JACVSD. The input parameters for

Ⅲ．Results

this database were initially the same as those of

The questionnaire recovery rate was 48% (n=266).

the database (STS National Database) used by the

1．Basic survey items

Society of Thoracic Surgeons (STS), but have been re-

Institutions participating in the JACVSD project

evaluated and gradually increased in number . The

accounted for 57%. In 82% of the 57%, JaSECT mem­

ICEBP perfusion case registry aims at establishingbers provided perfusion data necessary for JACVSD.

internationally common parameters. To respond

In 93%, there was an information terminal that canto this proposal, parameters reflecting the status

be used for tabulation or database application. In 87%

in Japan should be established for the perfusionof the 93%, access to the Internet was possible. The

database constructed by JaSECT, and a design thatdata processing application posses­sion rate (multiple-

9)

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Jpn J Extra-Corporeal Technology 39（2），2012

Table 1

Total number of perfusion procedures（1 Jan. - 31 Dec., 2010）
Procedure

Table 2

Location

n

CABG

4,563

Conversion OPCAB to CABG

240

CABG＋Valve（s）

1,849

CABG＋Other

918

Valve（s）

7,677

Aorta

4,961

Congenital（Adult）

707

Other

2,769

Total

23,684Temperature monitoring locations in CPB

In body

In line（n=244）

Percentage

Bladder

77.1

Nasopharnygeal

33.3

Esophageal

28.1

Jugular bulb

2.0

Rectal

78.7

Tympanic

28.6

Dorsum pedis

18.0

Dorsum manus

11.6

Arterial blood line

96.7

Venous blood line

91.9

Outlet of heat exchanger

45.7（n=249）

Table 3

Synchronous number of temperaturemonitoring locations

locations each in the body and lines (Table 3).

Number of locations

In body（%）

In line（%）

0

0.0

3.2

Myocardial protection using blood cardioplegia

1

5.2

4.4

was performed in 70%, and leukocyte removal was

2

40.2

47.0

performed in 2% of the 70%.

3

36.9

45.4

4

13.3

−

5

3.2

−

6

1.2

−
（n=249）Among biological monitoring parameters, glucose,electrolytes, hemoglobin, hematocrit, blood gas, andhemodynamics were monitored in the operating room(from admission to the room) and in the postoperative
intensive care unit in more than 90%. Renal function,
liver function, and protein were monitored in theanswer question) was 81% for MS-Excel, 51% foroperating room in less than 20% of the all institutions

FileMaker (FileMaker, CA, USA), and 33% for MS-(Table 4).

Access (Microsoft, WA, USA). Concerning the will to2）Circuit survey

participate in the perfusion case registration project,

There were 667 circuits in 248 institutions. The

95% answered that participation is “possible”.
The total number of perfusion cases during thearterial filter installation rate was 94%, and the filter
pore size was 30-40μm in 90% (Table 5).

1-year period from January 1, 2011 was 23,684 (n=244),

Replacement by carbon dioxide was performed forwhich consisted of 32% cases of coronary heart diseases,

the entire circuit in 16% of circuits, and only for the

32% cases of valve diseases, and 21% cases of aortic

arterial filter in 19%.

diseases (Table 1).

Circuits washed with solution such as Ringer’s

2．Perfusion survey items

solution accounted for 9%, and those with a prebypass filter accounted for 16%.

1）Institution survey

For pH management, theα-stat and pH-stat strate­

The perfusion recording method was only hand­writing in 53%, only automatic recording in 31%,

gies were used in 85 and 14%, respectively.

separate use of handwriting and automatic recording

The blood pump was the centrifugal pump indue to use of multiple pumps in 3%, and double

69% and the roller pump in 31%. Pulsate flow extra­

recording (both handwriting and automatic recording)corporeal circulation was used in 5%.
For drainage, gravity drainage, vacuum-assisted

in 13%.
The temperature monitoring location in the bodywas the rectum in 79%, and the bladder in 77%, andvenous drainage, and kinetic assist were used in 69,
26, and 5%, respectively.

that in the lines was the arterial blood line in 97%

The reservoir was the open type in 94% and theand venous blood line in 92% (Table 2). Temperature

closed type in 5%, and no reservoir was used in 1% .

monitoring was most frequently performed at 2

Circuits that can be used for selective cerebral

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Table 4

Biological monitoring parameters
Percentage of responding centers

Parameter

Biochemical test

Blood countBlood gas

Hemodynamics

In theatre
preCPBIn theatre
CPB

In theatre
postCPB

In recovery
room

Glucose

93.1

92.7

89.9

93.5

Na

96.0

98.0

94.4

95.2

K

95.6

97.6

94.0

94.8

Cl

87.9

89.1

86.3

91.1

Ca

92.7

93.1

90.7

91.9

Creatinine

14.1

5.6

9.7

79.0

BUN

17.7

10.5

13.7

79.0

AST

12.1

3.2

6.9

78.2

ALT

12.1

3.2

6.9

77.0

LD

10.1

0.8

5.6

75.4

Total protein

20.2

19.0

15.7

77.8

Albumin

14.1

10.5

11.3

73.8

Lactic acid

57.3

53.6

56.0

65.7

WBC

45.2

37.5

43.1

85.9

RBC

47.2

39.5

44.8

86.3

Hb

94.8

95.2

92.7

94.4

Ht

92.3

94.8

96.0

94.4

Platelets

45.6

37.1

45.2

86.3

pH

96.0

98.0

94.4

94.8

Pao2

96.0

98.0

94.8

94.8

Paco2

96.0

98.0

94.8

94.8

Spo2

94.4

91.9

92.7

92.7

Svo2

73.8

90.3

68.5

75.4

AOP

95.6

96.4

94.0

93.5

CVP

93.5

95.6

93.1

91.5

PAP

87.5

88.3

88.3

87.1

CI（or PI）

86.3

77.4

87.1

87.9
（n=248）

Table 5
Installation

Yes

No

Percentage

93.7

6.3

perfusion accounted for 35%.

Arterial filter installation
Pore size（μm）

Percentage

A survey of biocompatible coated circuits showed

〜 30

0.2

coating of the entire circuit including the cannula in

30 〜 40

90.2

23%, that excluding the cannula in 57%, and coating

40 〜 500.3

50 〜 100

2.7

of part of the circuit components in 20%. The coating

100 〜 150

0.6

150 〜 200

2.9

Unknown

3.0−−（n=666）

material was heparin in 40%, PMEA in 42%, silicon in
1%, and their combination in 14% (Fig. 1).
The buffer solution used as the primer solution was
Ringer’s solution in 87%, and colloidal solution wasadded to 26% of the 87% (Table 6). Blood preparations
with non-blood transfusion compositions were usedin 87%. Leukocytes were removed (using filters andirradiation) from blood preparations used for the
blood transfusion composition in 23%.

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Jpn J Extra-Corporeal Technology 39（2），2012

100％
Combination
Other

80％

Silicone
PMEA
Heparin

60％

40％

20％

0％

Tip to tip

All but cannulae

Figure 1

Table 6

Biocompatible coating on circuit surface

Priming solution for perfusion circuit
Percentage

Crystalloid（n=659）Colloid（n=174）

Limited components

only 80% of the collected perfusion case data werereliable without missing values, and improvements

0.9% Saline

8.0

Lactated Ringer

32.9

Acetic Ringer

33.2

Bicarbonate Ringer

20.8

Hartmanns

5.0Albumin（5%）

36.8

Hetastarch

18.4

perfusion case registration by displaying the pre­Albumin（25%）

44.8

sence/absence of missing data and summary, andsuch as data handling training to assure data quality
and confirmation of whether data are effective were
made. Takai et al. used a case registry interface produc­
ed using FileMaker for the unification of hospital data
for JACVSD registration 11). They solved problems in

improving convenience. In addition, in the JACVSD, site
visits to each institution to assure data quality are

Ⅳ．Discussion

performed. Therefore, using these coping methods

1．Basic survey items

for perfusion case registration in the future, theAs equipment requirements for perfusion casedatabase quality may be guaranteed.

registration, there are computers, Internet connection

The total number of registered JACVSD cases

circuits, and software. The former two were mostly

reached 100,000 in 2009, 8 years after the initiation

satisfactory in most institutions. As software, moreof registration, and the Japan Score was open tothan 90% of the institutions possessed MS-Excel or

the public. In October 2011, the number of cases

FileMaker. Therefore, the creation of interfaces forexceeded 159,000 12). Perfusion cases in all institutions

registration using these 2 types and a registrationthat responded to this survey accounted for 74%

work test can be the first step. Perfusion Downunderof all registered cases of the JACVSD in the same

constructed the Perfusion Downunder Collaborative

year (32,062 cases). If all institutions where JaSECT

Database (PDUCD), and compared collected data on

members work participate in the perfusion case regi­

open heart surgery with those in the Australasianstration project, and the number of registered cases

Society of Cardiac and Thoracic Surgeons (ASCTS)

steadily increase, not only the JACVSD but also a

database, and reported differences in data in thestatistically reliable analysis function will be able tosame parameters 6). PDUCD data during the 1-year

be provided early 12).

period after the initiation of registration (2007)

2．Perfusion survey items

were compared with those during the 2-year period1）Institution survey

from 2008, and a proposal to produce a high-quality

For the registration of data without mistakes,

database was reported 10). This report showed that

inputting as straightforward as possible is desirable.

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For this purpose, the automatic collection of perfusion

Circuits used for selective cerebral perfusion

data is necessary. Newland et al. constructed aaccounted for about 30% of all circuits. This selective

system in which almost all data are transmitted from

perfusion may have been used according to thean electronic medical recording system and a data

surgical technique because operations for aortic

collection system installed in the cardiopulmonary

diseases accounted for about 30% of all operations

bypass pump, and succeeded in improving the reliabi­

based on the annual number of patients for each6)

lity of data and reducing the registration work time .

disease category. The ICEBP parameters do not

In this survey, the number of institutions using

include parameters related to selective cerebral

handwriting for perfusion recording was slightly

perfusion. However, analysis in this field is important

higher than that of institutions using automatic rec­for perfusion in Japan, and we should independently

ording. In each institution, since a certain time isestablish parameters.

necessary for registration work by transferring eachThis survey suggested that the choices for eachcase using a keyboard, measures to reduce labor may

parameter of ICEBP’s perfusion registry can belead to the continuation of registration and assurance

mostly used. Many of the questions asked during thisof data reliability.

survey were concerned about the conversion method

Many biological parameters observed in this survey

due to differences in the concentration units of drugs

were not included in the ICEBP case registrationand the entry method due to differences between theparameters. Biological data necessary for perfusion

trade and chemical names of drugs. This is because

are quantitative data and closely involved in perfusion

the trade names of commercially available drugs

practice. In a previous study, a preoperative scoringand perfusion circuit products are commonly usedsystem was developed to evaluate the influences ofin clinical practice in Japan. In the case registration

perfusion on postoperative management 13). If theinterface, it may be convenient to use trade names

usefulness of this system can be supported, or thisof routinely used products at the time of inputting.

system can be improved for common nationwide

However, in the database, it is necessary to replaceuse, it will contribute to the preoperative prediction

the drug concentrations and names by those used inof outcomes. In this study, we also surveyed thethe ICEBP database.

presence or absence of measurement of parameters

Ⅴ．Conclusionnecessary for the calculation of the body fluid balanceusing quantitative blood analysis values, not depending

This survey suggested that the ICEBP, PDUCD,

on the fluid transfusion or urine volume. However,and BelSECT database parameters can be also usedsince measurement in the operating room is difficult,as database parameters in Japan. In addition, as aproblems remain.

result of the classification of open heart surgery2）Circuit survey

cases, almost equal numbers of perfusion cases of

The characteristics of the circuit composition incoronary heart diseases, those of valve disease, andJapan are a low pre-bypass filter incorporation rate

those of aortic diseases can be registered, suggesting

and a low circuit washing rate. As the blood pump, thean environment in Japan allowing globally valuable

percentage of circuits using a centrifugal pump wascharacteristic epidemiological evaluation.

more than twice that of circuits using a roller pump.
A survey performed in 2003 in Australia and New

Acknowledgments

Zealand showed a pre-bypass filter incorporation rate

This study was supported by a Grant-in-Aid forof about 90% and a roller pump usage rate of 70% 14).

Scientific Research from the Japanese Society for

Although simple comparison is difficult because no

the Promotion of Science (Challenging Exploratory

results of overseas surveys have been reported since

Research：No. 21659137) and the budget for thethis survey, the results of this survey markedly di­development of the guidelines of the Japanese Societyffer from those of our present survey. An on-the-of Extra-Corporeal Technology in Medicine (JaSECT)

spot survey in 2009 confirmed that the pre-bypass

We express deep gratitude to the institutions forfilter and roller pump are routinely used in Australia 8),

their cooperation and to the JaSECT members who

suggesting no marked changes in these differences.

responded.

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Jpn J Extra-Corporeal Technology 39（2），2012

We also thank Miho Ito, Chiaki Nakane, and Chihiro

Technology. BelSECT Perfusion Database.

Saito, students at the School of Health Sciences,

http://www.belsect.be/database/documents/Perfusiondatabase_2-0.pdf. 2010.

Fujita Health University, for their cooperation in data

8） Hibiya M, Kamei T, Kenmoku K, et al.：The investigationcollection in this survey.

of education and research of improving perfusion quality
in Australia. - The report of inspection to Flinders Medical

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