Monitored anesthesia care for the acute ischemic stroke patient with end-stage pulmonary disease

The majority of patients who suffer acute ischemic stroke (AIS) from large vessel occlusion are at a significant risk for disability or death. Because patients on veno-arterial extracorporeal membrane oxygenation (VA ECMO) are therapeutically anticoagulated, intravenous recombinant tissue plasminogen activator is contraindicated. For AIS management, these patients must undergo emergent intra-arterial therapy. Presented is a patient on VA ECMO who subsequently suffered a large vessel embolic stroke requiring emergent surgical intervention. The decision by our anesthetic team to perform the procedure under monitored anesthesia care is discussed.