What are the best management strategies for an 80-year-old female with diabetes and hypertension who died after a left below-knee amputation for diabetic foot complications?

Management of Elderly Diabetic Patients with Foot Complications: Preventing Mortality After Below-Knee Amputation

Early multidisciplinary team intervention is essential for elderly diabetic patients with foot complications to prevent mortality after amputation, with aggressive management of cardiovascular risk factors, infection control, and comprehensive post-operative care.

Risk Factors and Mortality

• Mortality after diabetic foot infection remains high and is significantly increased after major amputation, with one-year survival rates as low as 41.7% and five-year survival rates of only 8.3% following major amputation 1
• Major risk factors for mortality in elderly diabetic patients with foot complications include wound ischemia, advanced age, reduced kidney function, and elevated inflammatory markers 1
• Hypertension and diabetes are intertwined conditions that share significant overlap in underlying risk factors and complications, with up to 75% of adults with diabetes also having hypertension 2, 3
• Cardiovascular disease is the primary cause of morbidity and mortality in individuals with diabetes, and hypertension further aggravates this condition 4

Pre-Operative Management

• Comprehensive foot evaluation should be performed at least annually for all diabetic patients to identify risk factors for ulceration and amputation 5
• Early recognition of diabetic foot infections is critical, with prompt treatment to prevent amputation 6
• Aggressive cardiovascular risk management is essential as patients with diabetic foot ulcers and PAD have an overall 5-year mortality of approximately 50% 5
• Screening for peripheral arterial disease (PAD) should be conducted annually with clinical assessment and/or ankle-brachial index (ABI) measurement 6

Infection Management

• Moderate to severe infections require hospitalization and often surgical intervention 5
• Appropriate antibiotic therapy should be initiated after obtaining blood cultures and wound samples 6
• Surgical debridement of non-viable tissue is recommended for all diabetic foot ulcers 5
• Debrided tissue should be sent for microscopy, culture, and sensitivity to guide antibiotic therapy 6

Vascular Assessment and Management

• Evaluation of arterial circulation with detailed visualization of below-the-knee and pedal arteries using color Doppler ultrasound, CT angiography, or MR angiography is recommended 5
• Urgent vascular imaging and revascularization should be considered for patients with ankle pressure <50 mmHg or ABI <0.5 5
• Revascularization should aim to restore direct flow to at least one of the foot arteries, preferably the artery supplying the anatomical region of the wound 5
• In patients with diabetes and chronic limb-threatening ischemia (CLTI), revascularization is indicated whenever feasible for limb salvage 6

Perioperative Management

• Blood pressure control is critical, with a target of <130/80 mmHg for diabetic patients 6
• Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are recommended as first-line antihypertensive therapy for diabetic patients 6
• Glycemic control should be optimized with a target HbA1c of <7% to reduce microvascular complications 6
• Avoidance of hypoglycemia is essential, especially in elderly patients 6

Post-Operative Care

• Multidisciplinary care team approach is crucial for coordinated management to improve outcomes 6
• Regular monitoring of the amputation site for signs of infection or poor healing 6
• Aggressive management of cardiovascular risk factors including lipid control with statins (target LDL-C <1.4 mmol/L or <55 mg/dL) 6
• Antiplatelet therapy is recommended for all patients with diabetes and symptomatic PAD 6

Medication Management

• Consider SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) to reduce the risk of heart failure hospitalization and improve cardiovascular outcomes 6, 5
• GLP-1 receptor agonists (liraglutide, semaglutide, or dulaglutide) are recommended in patients with type 2 diabetes and cardiovascular disease to reduce cardiovascular events 6, 5
• Beta-adrenergic blocking drugs are effective antihypertensive agents and are not contraindicated in patients with PAD 6
• Statin therapy is recommended for all diabetic patients at high cardiovascular risk 6

Rehabilitation and Prevention of Contralateral Foot Complications

• Proper foot care education for the remaining foot, including daily inspection, appropriate footwear, and regular follow-up 6, 5
• Pressure-relieving footwear for the contralateral foot, especially if deformities are present 5
• Regular callus debridement by a foot care specialist 5
• Smoking cessation support is critical to reduce the risk of complications 6

Common Pitfalls and Caveats

• Failure to recognize the extremely high mortality risk after major amputation in elderly diabetic patients 1
• Inadequate management of cardiovascular risk factors, which contribute significantly to mortality 4, 3
• Delayed recognition and treatment of infection in the remaining foot 6
• Insufficient attention to kidney function, which is often compromised in elderly diabetic patients and affects medication choices 6
• Overlooking the psychological impact of amputation, which can affect rehabilitation and overall outcomes 7