To investigate surgical blood usage during the siege of Sarajevo.

Data on blood usage and pre-transfusion hematocrit (Hct) values from blood transfusion request forms in 250 wartime emergency surgical procedures during August through October 1992 (experimental group), and in 146 peacetime elective surgical procedures (control group) during April through June 1991 at the State Hospital of Sarajevo, were reviewed.

The mean number of blood units transfused per patient (blood usage rate) was 1.13 in the experimental group versus 2.56 in the control group (p <0.001). During the war, for blood conservation, normovolemic hemodilution was practiced widely. A significantly lower mean pre-transfusion Hct value of 0.21 was observed in the experimental group versus 0.27 in the control group (p <0.001).

Blood-usage rate was lower during emergency surgical procedures in war than during elective surgical procedures in peacetime without apparent adverse patient outcome. This decrease in blood-usage rate in the face of increased numbers of trauma victims was the result of a planned blood-conservation program which included: stringent blood-usage criteria, and widespread implementation of casualty resuscitation using normovolemic hemodilution with colloid and crystalloid plasma substitutes.

The safe and timely provision of blood is of crucial importance in the prevention and mitigation of morbidity and mortality due to trauma. The use of blood in the treatment of war casualties, soldiers as well as civilians, was analyzed retrospectively and the impact of massive blood transfusion on blood banking services and reserves of blood during the war in Sarajevo was assessed.

A retrospective analysis of 3,215 war casualties (1,815 civilians plus 1,400 military) who arrived to the casualty reception center of the State Hospital of Sarajevo during the period 11 May through 31 October 1992 was performed. Blood usage was reviewed in three stages: within 24 hours (h) of admission, after seven days of hospitalization, and after 30 days of hospitalization. The types of injury, survival rate, and blood-usage rate in a sample of 37 war casualties who required massive blood transfusions (MBT) during the period 11 May through 31 December 1992 was examined.

The civilian casualty rate in this series of patients was 56.5%. A total of 1,217/3,215 (37.9%) casualties were hospitalized. In this study, 16% (504/3,215) of total number of persons wounded received blood transfusion. Of these patients, 504/1,217 (41.4%) were transfused. A total of 971.1 liters of blood were transfused through 31 October 1992; 68% within 24 h of admission, 91% within the first seven days, and 100% within the first 30 days. From a total of 37 MBT recipients, 36 (97%) were injured by firearms. Survival rate among MBT patients was 30%. The MBT recipients comprised 2% of total hospitalized patients and 6% of total number of patients transfused. The amount of blood needed during episodes of MBT was 15% of total blood used through 31 December 1992.

Based on these data, prospective requirements for blood usage should take into account casualty triage, as follows: for each casualty transported to the hospital, hospitalized, or transfused, 0.302, 0.796, and 1.912 liters of blood respectively, will be needed for the first 30 days of treatment. Recipients of massive blood transfusions are a significant drain on blood reserves in war. This experience can be utilized in the development of revised guidelines for blood usage for an entire population affected by war.

Supplying an adequate amount of drinking water to a population is a complex problem that becomes an extremely difficult task in war conditions. In this paper, several simple methods for obtaining individual supplies of drinking water by filtration of atmospheric water with common household items are reported.

Samples of atmospheric water (rain and snow) were collected, filtered, and analyzed for bacteriological and chemical content. The ability of commonly available household materials (newspaper, filter paper, gauze, cotton, and white cotton cloth) to filter water from the environmental sources was compared.

According to chemical and biological analysis, the best results were obtained by filtering melted snow from the ground through white cotton cloth.

Atmospheric water collected during war or in extreme shortage conditions can be purified with simple improvised filtering techniques and, if chlorinated, used as an emergency potable water source.

In war, abdominal injuries constitute a significant proportion of the total injuries. These injuries are associated with high mortality and their treatment poses dianostic, surgical, and therapeutic dilemmas. This article presents the epidemiology of abdominal war injuries during the siege of Sarajevo, and briefly describes the surgical techniques and therapeutic practices used in their treatment.

A retrospective medical record review was performed of 273 war casualties with trauma to visceral and vascular structures in the abdomen inflicted during a 7.5 month period in 1992.

Most patients underwent exploratory laparotomy. Six percent had negative laparotomies, and there were no deaths in this group. In 18.3%, injuries were limited to one organ system, while 81.7% sustained combined injuries to multiple-organ systems. The crude mortality rate was 26.0%. Mortality rate excluding deaths within 24 hours of injury was 10.3%. Injuries were caused by metal fragments from artillery shrapnel, mortar and contact mines, or hand grenades. Because of a shortage of colostomy bags, resections of the colon with primary end-to-end anastomoses rather than colostomy were performed in 72% of the cases.

Mortality was highest in those victims with four or more injured organ systems (81.3%) or with major vascular injuries (64.7%). The primary cause of death within the first 24 hours was prolonged hemorrhagic shock.

An epidemic of surgical wound infections observed at the State Hospital of Sarajevo during June-September 1992 is reported.

A cross-sectional survey of 138 surgical patients with wound infection treated by the Department of Surgery of the State Hospital of Sarajevo was performed in mid-September and again in mid-November 1992. A preliminary evaluation of the bactericidal effectiveness of a new antiseptic preparation called DI-ASEPT also was done.

The frequency of wound infection was 24.4% in September and 19.2% in November. Pseudomonas species was the primary etiologic agent in this epidemic. DI-ASEPT was as effective as povidone-iodine in producing wound asepsis.

Because of limited resources large numbers of casualties, and an extremely adverse environment as a result of war that has affected hygienic conditions at the State Hospital of Sarajevo, a high frequency of contaminated or dirty operations were performed. This was the primary reason for the observed increase in wound infections. After hygienic conditions were restored, the epidemic of wound infections was terminated.

The siege of Sarajevo is a longterm, human-made, medical disaster of international significance. The delivery of emergency health care provided to the large civilian population held captive in that war zone for an extended time was studied.

In May 1993, a humanitarian and fact-finding visit to Sarajevo was conducted. Physicians, administrators, and public health officials were interviewed; epidemiological data were acquired—the resuscitation of war casualties at the two largest hospitals were observed; and local published reports and videotaped footage on the organization and delivery of prehospital and hospital care were reviewed. The videotapes also served to document war crimes.

Daily bombardment and sniper fire directed at civilians have caused a steady stream of casualties (64,130, or an average of 119 killed or injured per day in 18 months). Eighty percent of the victims were civilian. Despite hazardous conditions from direct shelling, disruption of vital lifelines, and shortage of supplies, medicines, oxygen, and anesthetics, the physicians continue to provide at least a minimum standard of resuscitative care. Seventy percent of all war victims were transported to hospitals in private vehicles. Most casualties (93%) received some form of prehospital, basic first-aid from lay bystanders or first responders. From November 1992 to February 1993, 27,733 patients were treated in hospitals, resulting in 2,139 major surgical procedures. The primary cause of death in 71 of 273 victims was prolonged hemorrhagic, hypovolemic shock. Sixty-one percent of these victims died within 24 hours of injury.

Continuous needs assessment be accompanied by rapid delivery of outside aid. International “peacekeeping” forces should protect hospitals and their staffs, and ensure the entry of supplies and evacuation of some patients. A public trained in life-supporting first-aid, and physicians and paramedics with experience in advanced life support may have enhanced lifesaving efforts in Sarajevo.