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).