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• Monitor the extremity for color, sensation, and temperature, being watchful for the five Ps of acute lower extremity ischemia indicating graft occlusion or acute thrombosis:
  • Pain
  • Pallor
  • Pulselessness
  • Paresthsias
  • Paralysis
  • (Poikelothermia is often added as the sixth P)
• Monitor the Doppler signals in the feet (see Figure 36-2), which are usually marked with an X in the OR. If they have not yet been marked, mark them so that others will check in the same location; do not depend on palpating the pulse. If the Doppler signal is not appreciated, the surgeon should be notified immediately.

  Figure 36-1 Bypass surgery

• A Doppler signal should also be present over the graft. If it cannot be appreciated the surgeon should be notified immediately as it may indicate graft thrombosis.
• Maintain normothermia; keep the extremity warm.
• Prevent pressure on the heel and bony prominences. Even tight dressings can injure the skin and cause breakdown.
• Monitor blood pressure and prevent hypotension, which can cause acute graft occlusion.
• Monitor for compartment syndrome, which can occur in an extremity that was ischemic for more than 6 hours before reperfusion. The earliest signs of compartment syndrome include pain in the leg associated with sensory deficits on the dorsum of the foot and weakness of toe dorsiflexion. The treatment is fasciotomy. Often, prophylactic fasciotomy is performed at the time of revascularization.
• Monitor for hemorrhage, and check for hematoma in the groin or leg. In a patient with

  Figure 36-2 Monitor Doppler

  aortoiliac reconstruction, retroperitoneal hemorrhage can occur and should be suspected with tachycardia and hypotension not responsive to fluids and pressors.
• Patients with end-stage or chronic renal disease can be among the sickest, most fragile patients due to multiple comorbidities and often advanced age. Most often, arteriovenous (AV) fistula or graft creation is a day surgery, and patients are observed for a comparatively short period of time.