Jehovah's witness lady with Hb 9,8 for bilateral mastectomy - breast cancer

[VR]

Hallo,
I am dealing with reasonably fit 40 yrs old lady, Jehovah's witness.
On her preop. 3 weeks ago - sideropenic anaemia with Hb 9,8.
She is listed for bilateral mastectomy with breast reconstruction, relatively large procedure with potential of not sudden, but in total big blood lost.
I recommend postpone operation and go on with iron treatment.
Surgeon wants to proceed because from oncological reason.
I suggest invite a haematologist, take his advice and written recommendation with estimation of how long it would take to have her Hb level within the normal range. Surgeon can make decision if there is any substantial risk with postponing the surgery.
Would you thing that making decision in a team haematologist – surgeon – anaesthetist is a proper one?
What would you recommend?

[jafo1964]

40 years - No comorbid factors can tolerate fall in Hb to 7 mg ( HCT 25%)
currently her HCt is 30% ( Hb of 10)

She must be 60 kg
Her estimated Blood volume is 4200 ml

Her allowable blood loss to reach a Hct of 25% is about 650 ml.
Should try and restrict the blood loss to that level.

Waitng to improve Hb using Iron could take too long and may lead to dissemination of malignancy
Iron supplemented with Erythropoetin, both parenterally may improve Hb faster.

After discussion with the surgeon I will proceed with surgery and use techniques to mininmize blood loss using intraoperative Normovolemic hypotension within lowest acceptable limits.

Since she is an ASA 1 patient I would maintain MAP between 50 to 55 mm Hg.

Oral premed - Oral Benzodiazepine + oral clonidne 2mcg/kg

Fent 2 mcg/kg + Lignocard 1.5 mg /kg
Propofol 2 mg/kg + Vecuronium 0.1 mg/kg
N20 66% + O2 33% + Isoflurane 1%
Vec + Fent as needed

Restrictive fluid protocol to maintain Uo of 0.5 ml/kg/hr

Hypertension

beta blockers ( if HR >70) + Ntg titrated to maintain MAp to desired levels.

Reverse and extubate whn fully awake

Intraop hypo to be managed with crystalloids, colloids and vasopressors

What more is the haematologist going to do on this case

regs