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Background and Aims Preoperative optimization of anemia is particularly important in Jehovah’s Witnesses before major surgery. However, when presenting in an acute setting there are no recommendations, and a multimodal and multidisciplinary approach is necessary to safely deliver treatment. Regional anesthesia has a particular role in reducing complications.

Methods Case report.

Results A 74-year-old male was admitted in our institution for above-knee amputation of the left lower extremity due to irreversible ischemia. His past medical history was relevant for multiple myeloma, hypertension and type 2 diabetes mellitus. His baseline hemoglobin was 7.7 g/dL. He was a Jehovah’s Witness who refused blood transfusions, having been transferred from another institution, where he was denied surgery. Two days before surgery, ferric carboxymaltose 500 mg was administered. Surgery was performed under combined spinal-epidural anesthesia, with 7 mg of intrathecal hyperbaric bupivacaine. Before the beginning of surgery, tranexamic acid 1 g was administered. Hemodynamic stability was achieved, with minimal blood loss (200 mL). The final hemoglobin was 6.4 g/dL. For postoperative analgesia a multimodal approach was implemented, with patient-controlled epidural analgesia with ropivacaine 0.2%. After surgery, darbepoetin alfa 500 micrograms was administered. He was transferred back to his original institution after two days.

Conclusions Lower extremity amputation carries a significant risk of perioperative morbidity and mortality. Regional anesthesia may confer several advantages over general anesthesia, having demonstrated a reduction of blood transfusion requirements in the setting of lower extremity amputation. Therefore, it should be considered as part of a blood conservation strategy.

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