Rev. Bras. Anestesiol. vol.65 número6

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

SCIENTIFIC

ARTICLE

Assessment

of

the

perioperative

period

in

civilians

injured

in

the

Syrian

Civil

War

Sedat

Hakimoglu

_,

_Murat

_Karcıoglu

_,

_Kasım

_Tuzcu

_,

_Isıl

_Davarcı

_,

_Onur

_Koyuncu

_,

˙Ismail

Dikey

_,

_Selim

_Turhanoglu

_,

_Ali

_Sarı

_,

_Mehmet

_Acıpayam

_,

_Celalettin

_Karatepe

a_{DepartmentofAnesthesiologyandReanimation,MustafaKemalUniversity,FacultyofMedicine,Hatay,Turkey} b_{DepartmentofCardiovascularSurgery,MustafaKemalUniversity,FacultyofMedicine,Hatay,Turkey}

Received9January2014;accepted10March2014

Availableonline3April2014

KEYWORDS

SyrianCivilWar; Perioperativeperiod; Warinjury

Abstract

Background: wars and its challenges have historically afflicted humanity. In Syria, severe injuriesoccurredduetofirearmsandexplosivesusedinthewarbetweengovernmentforces andciviliansforaperiodofover2years.

Materialsandmethods: thestudyincluded364cases,whowereadmittedtoMustafa Kemal UniversityHospital,MedicineSchool(Hatay,Turkey),andunderwentsurgery.Survivorsand non-survivorswerecomparedregardinginjurysite,injurytypeandnumberoftransfusionsgiven. Themortalityratefoundinthisstudywasalsocomparedtothosereportedinothercivilwars.

Results:themeanagewas29(3---68)years.Majorsitesofinjuryincludedextremities(56.0%), head (20.1%), abdomen (16.2%), vascularstructures (4.4%) andthorax (3.3%). Injury types includedfirearminjury(64.4%),blastinjury(34.4%)andmiscellaneousinjuries(1.2%).Survival ratewas89.6%whilemortalityratewas10.4%.Asignificantdifferencewasobservedbetween mortalityratesinthisstudy andthose reportedfortheBosnia andLebanoncivil wars;and thedifferencebecameextremelyprominentwhencompared tomortalityratesreportedfor VietnamandAfghanistancivilwars.

Conclusion: among injuries related to war, the highest rate of mortality was observed in head---neck, abdomenandvascularinjuries. Webelieve thatthehighermortalityrateinthe SyrianCivilWar,comparedtotheBosnia,Vietnam,LebanonandAfghanistanwars,isdueto seeingciviliansasadirecttargetduringwar.

© 2014SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.

∗_{Correspondingauthor.}

E-mail:[email protected](S.Hakimoglu).

http://dx.doi.org/10.1016/j.bjane.2014.03.003

PALAVRAS-CHAVE

GuerraCivilSíria; Período

pós-operatório; Lesõesdeguerra

Avaliac¸ãodoperíodoperioperatórioemcivisferidosnaGuerraCivilSíria

Resumo

Justificativa:Historicamente,asguerraseseusdesafiosafligemahumanidade.NaSíria,lesões gravesocorreramdevidoàsarmasdefogoeexplosivosusadosnaguerraentreasforc¸as gover-namentaisecivisduranteumperíododemaisdedoisanos.

Métodos: Oestudoincluiu364pacientes,admitidosnoHospitaldaUniversidadeMustafaKemal daFaculdade deMedicina(Hatay,Turquia)e submetidosàcirurgia. Ossobreviventese não sobreviventes foramcomparados quanto ao local etipo da lesão e número de transfusões administradas.Ataxademortalidadeencontradanesteestudotambémfoicomparadaàquelas relatadasemoutrasguerrascivis.

Resultados: Amédia deidade foide29 (3-68)anos. Osprincipaislocais delesão incluíram extremidades(56,0%),cabec¸a(20,1%),abdome(16,2%),estruturasvasculares(4,4%)etórax (3,3%).Ostipos delesõesincluíram ferimento de armadefogo (64,4%),lesão causada por explosão(34,4%)eferimentosdiversos(1,2%).Ataxadesobrevivênciafoide89,6%,enquanto ataxade mortalidadefoi de10,4%.Observou-se umadiferenc¸a significativaentreastaxas demortalidadenesteestudoeaquelasrelatadasparaasguerrascivisdaBósniaeLíbano;e adiferenc¸aficouextremamentesignificativaquandocomparadacomastaxasdemortalidade relatadasparaasguerrascivisdoVietnãedoAfeganistão.

Conclusão:Dentreaslesõesrelacionadasàguerra,amaiortaxademortalidadefoiobservada emlesõesdecabec¸a-pescoc¸o,abdomeevasculares.Acreditamosqueamaiortaxade mor-talidadenaGuerraCivildaSíria,em comparac¸ãocomasguerrasdaBósnia,Vietnã,Líbano Afeganistão,sedevaaofatodeoscivisteremsidovistoscomoalvodiretoduranteaguerra. ©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.

Introduction

Wars andits challengeshave historically afflicted human-ity and continue to do so today.1 _{War trauma is the}

most important risk for public health. During wars, sev-eral life-threatening injuries occur to military personnel and civilians. However, during war the majority of peo-pleinjuredordeadarecivilians2,3_{;unfortunately,civilians}

comprise over 80% of injured individuals during armed conflicts.4

In the past, deaths were due to secondary effects of war (lack of sheltering, hunger, infections), while today, increasedmortalityandmorbidity of civiliansaredirectly related to war itself.5 _{The reason for this is that}

civil-iansaresometimes seenasdirecttargets duringwar. The typeofarmed conflictonthebattlefieldalsoaffectsthe type of injury sustained. Today, modern weapons cause severeinjuries.Themajorityofpatientsarethereforethose injuredbyfirearmsandexplosives.5---8

In Syria, severe injuries occurred due to firearms and explosivesusedinthewarbetweengovernmentforcesand civilians for a period of over 2 years. Although patients injured by firearms and explosives are transferred to regionaltraumacentersimmediatelyafterbeingfound,the most common cause of death is coagulopathy and shock resultingfromsevere blood loss.9_{As rapid fluid}

resuscita-tionisperformed,hypothermiaandacidosisdevelopinthese patients.Inaddition,dilutional coagulopathy isinevitable duetotheuseofcrystalloidsandplasma-poorblood prod-uctsduringreplacement.10,11

The majorsiteofan injury isan importantfactor that affectssurvival.Inadditiontothemajorsiteofan injury, injurymechanismalsoinfluencessurvival.12,13

CivilwarintheneighboringnationofSyria,hasaffected thehealthcaresectoraswellastheeconomy,lackof shel-teringandfoodsectorsinTurkey.As inallhospitalaround theborder,thereisalsoamarkedincreaseinthenumberof severelyinjuredpatientspresentingtoourhospital.Aimof thisstudyistheeffectonmortalityofinjurysitesandtypes, alsoreviewofperioperativeperiodinpatientsinjuredduring theSyrianCivilWar.

Materials

and

methods

Table1 Demographicdata.

Min Max Mean SD

Age(year) 3 68 29.05 11.53

HR(beats/min) 7 171 99.05 22.53

SpO2(%) 48 100 98.29 4.12

SAP(mmHg) 49 178 119.1 22.03

DAP(mmHg) 17 108 70.61 15.82

Glasgow 3 15 13.68 2.95

Operationduring(min) 20 475 149.74 96.70

Bloodproduct(U) 0 68 3.4 7.48

Sex(%) Male Female

94 6

Anesthesiamethod(%) General Regional

91.4 8.6

inthisstudywasalsocomparedtothosereportedinother civilwars(Bosnia,1992;Vietnam,1978;Lebanon,1982;and Afghanistan,1988).

SPSSforWindowsversion15.0wasusedfordataanalysis. The Kolmogorov---Smirnovtest wasusedtoassess distribu-tionofgroups.TheKruskal---Wallistestwasusedtocompare independentgroupswithoutnormaldistribution,while the Mann---WhitneyUtestwasusedforbinarycomparisonswithin groups.Proportionalcomparisonwasusedtocompare mor-tality rates. p<0.05 was considered as significant for all tests.

Results

Of the 364 cases included, general anesthesia was used in 91.4% whereas regional anesthesia was used in 8.6% of case. The mean age was 29 (3---68) years. The mean preoperative hemoglobin value was 11 (3.5---16.9)g/dL. The mean number of blood transfusions per patient was 3.4 units throughout the hospital stay (Tables 1 and 2). Major sites of injury included extremities (56.0%), head (20.1%), abdomen (16.2%), vascular structures (4.4%) and

Table2 Bloodproductuseandhemogramvalues.

Min Max Mean SD

PreoperativeHgb (g/dl)

3.5 16.9 11 2.5

PreoperativeHtc(%) 9.9 47.9 32.7 8

Preoperativeplatelet (103_/

␮L)

16 1205 330.9 193.1

PostoperativeHgb (g/dl)

5.9 15.1 10.3 2

PostoperativeHtc(%) 18.1 44.5 30.8 6.2

Postoperative platelet(103_/

␮L)

60.6 1146 338.6 225.2

ES(Unit) 0 50 2.6 5.4

Wholeblood(Unit) 0 1 0 0.1

FFP(Unit) 0 22 0.8 2.6

Totalbloodproducts (Unit)

0 68 3.5 7.5

20%

56%

Head and neck Extremity Chest

Abdomen Vascular

3%

16% 5%

Figure1 Distributionofpatientsaccordingtoinjurysite.

thorax(3.3%)(Fig.1).Injurytypes includedfirearminjury (64.4%), blast injury (34.4%) and miscellaneous injuries (1.2%) (Fig. 2). When all patients included were consid-ered,survivalratewas89.6%whilemortalityratewas10.4%. Moreover,the total number of blood products washigher in non-survivors when compared to survivors (p<0.01; Fig.3). When compared according to injury type, it was found that the most commonly observed injury was blast injuries (57.6%) among non-survivors and firearm injuries (65.1%)amongsurvivors;however,therewasnosignificant difference(Fig.4).Whencomparedaccordingtoinjurysite, itwasfoundthat head---neck andabdominalinjurieswere

%64

Firearm Burn Other

%35

%1

Total blood products (Unit)

Non-survivor Survivor

0 2 4 6 8 10 12

*

Figure3 Totalnumberofbloodproductsgiventosurvivors andnon-survivors(*p<0.01).

80

70

60

50

Non-survivors (N) Survivor (N) 40

30

20 10

0

Head and nec k

Extremity

Chest

Abdomen Vascular

*

**

** *

Figure4 Comparisonofsurvivorsandnon-survivorsaccording toinjurysite(*p<0.05;**p<0.01).

significantlyhigher,whilevascularinjurieswereextremely higher,amongnon-survivors.Extremityinjuriesweremore commonamongsurvivors (Fig.5).A significant difference wasobservedbetweenmortalityratesinthisstudyandthose reportedfortheBosniaandLebanoncivilwars;andthe dif-ference became extremely prominent when compared to mortalityrates reportedforVietnamandAfghanistancivil wars(p<0.001;Table3).

70

60

50

40

30

20

10

0

Firearm Burn Other

Survivor Non-survivors

Figure 5 Survival and mortality rates according to injury type.

Table3 ComparisonofmortalityrateintheSyrianCivilian Warwithothercivilwars.

Survivor(n) Dead(n) % p

Syria 333 31 8.5

Bosnia 1527 91 5.6 <0.05

Vietnam 17405 321 1.8 <0.001

Lebanon 1475 86 5.5 <0.05

Afghanistan 195 5 2.5 <0.001

Discussion

In several wars, difficulties in transferring patients from the combat areato healthcarefacilities, aswell as chal-lenges in triageandevacuation, havecaused increases in mortality and morbidity rates.14,15 _{The survival and}

mor-tality rates were 89.6% and 10.4%, respectively, in this study,which aimed toassessperioperative periods of the patientswhounderwentsurgeryintheHospitalofMustafa KemalUniversityHospital,MedicineSchool,duetoinjuries occurred during the SyrianCivil War. In the literature, it wasreportedthatmortalityrates,afterarrivingat health-care facilities, were less than 6% in Italy (1944---1945), Korea(1950---1953),Vietnam(1964---1973),NorthernIreland (1970---1984)andAfghanistan(1979---1989)wars.16_Inanother

study,in-hospitalmortalityratewasreportedas5.6%inthe Bosniawar.12_{Themortalityrateinourstudywasfoundtobe}

higherwhencomparedtothoseinBosnia,Vietnam,Lebanon andAfghanistanwars(Table3).Furtherincreasein mortal-ityratewaspreventedbythepresenceofacountyhospital betweentheborderareaandourhospital.

Despitedebates onthe contributionof urbanconflicts, it is known that several factors influence the ambiguity ofvaryingmortalityrates.Today,mostinjuriesarecaused by firearms or explosive materials.17 _{The type of injury}

may vary according to intensity of conflict and status of weapon and ammunition of parties. Firearm injuries are morefrequentlyobservedinlow-intensityconflicts, asym-metricalwar,urbanoperationsagainstterrorismandspecial tasks(e.g.foresttaskduringtheVietnamWar).19---26_Firearm

injurieshavemorefatalcoursethanthosecausedby explo-sives or shell.13 _{In our study, most commonly observed}

injuries were firearm injuries; followed by blast injuries andmiscellaneousinjuries(p<0.01).Inthisstudy,firearm injuriesweremorecommonamongnon-survivorswhen com-pared to survivors, and the difference was statistically significant.

Althoughthemostcommonlyseeninjurysitewaslower extremities, most fatal injuries were those of the head and caused by firearms.5,17 _{Also, mortality rate is higher}

among patients with head, thorax and abdomen injuries comparedtothosewithotherinjuries.12_{Extremitywasthe}

most commoninjury sitein theBosnia,Vietnam,Lebanon and Afghanistan wars.12 _{In a study on pelvic, spinal and}

ofallmusculoskeletalinjuries.27_{Additionally,lower}

extrem-itywascitedasthemostcommontargetamongsurvivors. However,abdominalinjuriestended tobemorefatal.28 _In

ourthisstudy,themajoranatomicalinjurysitewas extrem-ity;followedby head.Inaddition,mortalitywasfoundto behigherinheadinjuriesaswellasabdominalandvascular injurieswhencomparedtootherinjurysites.

Hemorrhage is the major cause of mortality in war injuriesandithasbeenshownthatbloodlossistheleading causeofdeathwithinonehourafterinjury.29_{Inwar-related}

traumas,severe hemorrhage is the most significant cause ofdeathin civiliansandmilitarypersonnel.30 _{Robust fluid}

therapy isindicated in mostlosses atthe battleareaand ithasbeenreportedthatanti-shocktrousersarebeneficial for war injuries.31 _{In a study on 4470cases of war injury}

admittedto4hospitals,itwasreportedthattheamountof bloodproductneededwas44.9unitsper100patients.32 _It

was3.4unitsperpatientinourstudy.Onaclinicaltrialof combatcasualties,theBoardfortheStudyoftheSeverely Woundedreportedthatcauseof deathwashemorrhagein combatcasualties duringlast6monthsoftheWorldWarII inItaly.18 _{Inthisstudy,itwasseenthathigheramountsof}

bloodproductswereneededinnon-survivors.

In conclusion, amonginjuries relatedtowar, the high-estrateofmortalitywasobservedinhead---neck,abdomen and vascular injuries.The highest numberof injuries was observedattheextremities.Webelievethatthehigher mor-talityrateintheSyrianCivilWar,comparedtotheBosnia, Vietnam,Lebanon andAfghanistan wars,is due to seeing civilians as a direct target during war. Injury mechanism andsitevaryaccordingtothelocationoftheconflict.Thus, thereisneedfor moreextensivestudiesthatinvestigating thefactorsaffectingmortalityencompassinghospitalsatthe borderthatprovidehealthcaretoindividualsinjuredinthe SyrianCivilWar.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

1.Gosselin RA. War injuries, trauma, and disaster relief. Tech Orthop.2005;20:97---108.

2.GarfieldRM, NeugutAI.Epidemiologicanalysisofwarfare:a historicalreview.JAMA.1991;266:688.

3.MeddingsDR.Civiliansand war:a reviewandhistoricalover viewoftheinvolvementofnon-combatantpopulationsin con-flictsituations.MedConflSurviv.2001;17:6---16.

4.Atiyeh BS, Hayek SN. Management of war-related burn injuries:lessonslearnedfrom recenton going conflicts pro-vidingexceptional care inunusual places. JCraniofac Surg. 2010;21:1529---37.

5.AboutanosMB,BakerSP.Wartimecivilianinjuries:epidemiology andinterventionstrategies.JTrauma.1997;43:719---26.

6.SmithJE.Theepidemiologyofblastlunginjuryduringrecent militaryconflicts:aretrospectivedatabasereviewofcases pre-sentingtodeployedmilitaryhospitals,2003---2009.PhilosTrans RSocLondBBiolSci.2011;366:291---4.

7.Atiyeh BS, Gunn SW, Hayek SN. Military and civilian burn injuries during armed conflicts. Ann Burns Fire Disasters. 2007;20:203---15.

8.OwensBD,KraghJrJF,WenkeJC,etal.Combatwoundsin oper-ationIraqiFreedomandoperationEnduringFreedom.JTrauma. 2008;64:295---9.

9.HessJR,HolcombJB.Transfusionpracticeinmilitarytrauma. TransfusMed.2008;18:143---50.

10.MurrayDJ,PennellBJ,WeinsteinSL,etal.Packedredcellsin acutebloodloss:dilutionalcoagulopathyasacauseofsurgical bleeding.AnesthAnalg.1995;80:336---42.

11.KetchumL,HessJR,HiippalaS.IndicationsforearlyFFP, cryo-precipitate,andplateletsintrauma.JTrauma.2006;60:51---8.

12.VanRooyenMJ,SloanEP,RadvanyAE,etal.Theincidenceand outcomeofpenetratingandblunttraumaincentralBosnia:The NovaBilaHospitalforWarWounded.JTrauma.1995;38:863---6.

13.Hardaway 3rd RM. Viet Nam wound analysis. J Trauma. 1978;18:635---43.

14.RautioJ,PaavolainenP.Afghanwarwounded:experiencewith 200cases.JTrauma.1988;28:523---5.

15.Rignault DP. Abdominal trauma in war world. J Surg. 1992;16:940---6.

16.BellamyRF.Combattraumaoverview.In:ZajtchukR,Grande CM,editors.Textbookofmilitarymedicine,anesthesiaand peri-operativecareofthecombatcasualty.FallsChurch,VA:Office oftheSurgeonGeneral,UnitedStatesArmy;1995.p.1---42.

17.SakorafasGH,PerosG.Principlesofwarsurgery:current con-ceptsandfutureperspectives.AmJEmergMed.2008;26:480---9.

18.ChampionHR,BellamyRF,RobertsCP,etal.Aprofileofcombat injury.JTrauma.2003;54:13---9.

19.Marshall TJ. Combatcasualty care:the Alpha Surgical Com-pany experience during operation Iraqi Freedom. Mil Med. 2005;170:469---72.

20.PatelTH,WennerKA,PriceSA,etal.AU.S.Armyforward sur-gicalteam’sexperienceinOperationIraqiFreedom.JTrauma. 2004;57:201---7.

21.RyanJM,CooperGJ,HaywoodIR,etal.Fieldsurgeryonafuture conventionalbattlefield:strategyandwoundmanagement.Ann RCollSurgEngl.1991;73:13---20.

22.BowyerGW.AfghanWarwounded:applicationoftheredcross woundclassification.JTrauma.1995;38:64---7.

23.Mannion S, ChalonerE. Principlesofwar surgery. Br MedJ. 2005;330:1498---500.

24.Coupland RM. The effect of weapons: defining superfluous injuries and unnecessary suffering. A1 Med Global Surviv. 1996;3.

25.Souka HM. Management of gulf war casualties. Br J Surg. 1992;79:1307---8.

26.Montgomery SP, Swecki CW, Shriver CD. The evaluation of casualtiesfromOperationIraqiFreedomonreturntothe conti-nentalUnitedStatesfromMarchtoJune2003.JAmCollSurg. 2005;201:7---12.

27.SchoenfeldAJ,DunnJC,BelmontPJ.Pelvic,spinaland extrem-itywoundsamongcombat-specificpersonnelservinginIraqand Afghanistan(2003---2011):anewparadigminmilitarymusculo skeletalmedicine.Injury.2013;44:1866---70.

28.Odhiambo WA, Guthua SW, Chindia ML, et al. Pattern and clinical characteristics of firearm injuries. East Afr Med J. 2008;85:107---12.

29.PengR,ChangC,GilmoreD,etal.Epidemiologyofimmediate andearlytraumadeathsatanurbanlevelItraumacenter.Am Surg.1998;64:950---4.

30.SauaiaA,MooreFA, MooreEE,etal.Epidemiologyoftrauma death:areassessment.JTrauma.1995;38:185---93.

31.Wiedeman JE, Rignault DP. Civilian versus military trauma dogma:whodoyoutrust?MilMed.1999;164:256---60.