Evidence-based management of anaemia in severely injured patients.

SEVERE injuries are the leading cause of death in the world population below 45 years of age (1). Exsanguination is a major factor contributing to mortality in these patients. Thus, haemorrhage control and volume resuscitation have high priority in Advanced Trauma Life Support (ATLS) principles. The rationale during acute treatment is the maintenance of oxygen delivery and adequate tissue oxygenation. Early resuscitation after haemorrhagic shock, according to ATLS, comprises 2 l of crystalloid solution, followed by packed RBC transfusion to maintain haemoglobin between 7 and 9 g/dl (2). Once resuscitated and monitored in the intensive care unit (ICU), trauma patients receive repeatedly packed RBC transfusions to induce an increase in the haemoglobin concentration often even days after the initial trauma. Corwin et al. (3) reported that more than 44% of all patients (n5284) in the ICU needed red blood cell (RBC) concentrates, with a mean of 4.6 units. Livingston et al. (4) reported that more than 80% of the trauma patients in the ICU received weekly blood transfusions, while only 35% of transfusions are related to an acute blood loss (5). It is apparent that the need for blood transfusions is prolonged and extends to even long after the initial injury. In these patients, haemorrhage is only one cause of persistent anaemia. Triggered by systemic inflammation after multiple trauma bone marrow dysfunction due to a blunted erythropoietin (EPO) response, reduced iron availability and loss of erythroid progenitors through apoptosis and egress seem to cause chronic anaemia similar to anaemia of chronic disease (6).