Unfractionated heparin has long been considered the standard anticoagulation in ECMO, despite some pitfalls such as heparin resistance, heparin induced thrombocytopenia (HIT), etc Recently, some centres started to increasingly use argatroban for this purpose, typically using activated partial thromboplastin time (aPTT) for its monitoring. Direct monitoring of the efficacy of argatroban using Anti-IIa is not yet an established method, although it might be more appropriate as it targets the same pathway.An observational study was performed in adult veno-venous ECMO patients hospitalized with SARS-CoV-2 infection anticoagulated with argatroban to an aPTT target of 40-60 s and Anti-IIa target of 0.4-0.6 µg/mL. Bleeding and thrombotic complications were monitored.Forty-four VV ECMO patients were included, with an overall hospital mortality of approx. 50%. No life-threatening thrombotic events were recorded. The risk of bleeding complications significantly increased with aPTT above 52.7 s and with Anti-IIa values over 0.78 µg/mL. Using the above cut-offs for both the aPTT and Anti-IIa and their combination, the negative predictive value for bleeding was approximately 90%.It seems that the generally recommended limits for Anti-IIa of 1.5 µg/mL may be high. However, further data are needed to confirm lower limits.Trial Registration:retrospectively registered in ClinicalTrials.gov, NCT06038682.

• Keywords
• Anti-IIa, activated partial thromboplastin time (aPTT), anticoagulation, argatroban, extracorporeal oxygenation (ECMO), monitoring,
• MeSH
• Anticoagulants * therapeutic use   adverse effects   administration & dosage   MeSH
• Arginine analogs & derivatives   MeSH
• COVID-19 * blood   therapy   mortality   complications   MeSH
• Adult MeSH
• COVID-19 Drug Treatment * MeSH
• Hemorrhage chemically induced   MeSH
• Pipecolic Acids * therapeutic use   administration & dosage   adverse effects   MeSH
• Middle Aged MeSH
• Humans MeSH
• Extracorporeal Membrane Oxygenation * methods   MeSH
• Drug Monitoring methods   MeSH
• Partial Thromboplastin Time MeSH
• SARS-CoV-2 MeSH
• Aged MeSH
• Sulfonamides MeSH
• Thrombosis prevention & control   etiology   MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Observational Study MeSH
• Names of Substances
• Anticoagulants * MeSH
• argatroban MeSH Browser
• Arginine MeSH
• Pipecolic Acids * MeSH
• Sulfonamides MeSH

During the COVID-19 pandemic, specific COVID-19-related conditions renewed interest in the full-awake venovenous extracorporeal membrane oxygenation ( fa V-V ECMO) approach, in which ECMO is applied to awake, cooperative, and non-intubated patients. This scoping review aims to provide a descriptive overview of fa V-V ECMO in patients with COVID-19-related acute respiratory distress syndrome (CARDS). We searched the PubMed, Web of Science, and Scopus databases using the keywords "awake ECMO" or "spontaneous breathing AND ECMO", combined with "COVID-19", "SARS-CoV-2" or "coronavirus", utilizing the Boolean operator "AND". The search included papers published from November 1, 2019, to December 31, 2024. Sixty-four papers were assessed for eligibility at the abstract level, and fourteen articles (seven small-sample cohort studies and seven case reports) comprising 95 patients were included in the final analysis. The most frequent reasons for preferring fa V-V ECMO over mechanical ventilation were barotrauma and patient refusal of intubation and mechanical ventilation. The fa V-V ECMO strategy was successful (ie, patients not intubated, disconnected from ECMO, and discharged from the hospital) in 36.4% of cases (cohort studies only). The incidence of defined severe adverse events (bleeding, thrombosis, cannula malposition, delirium, and progression of barotrauma) was considered low. The mortality rate for CARDS patients treated with fa V-V ECMO (including only patients from cohort studies) reached 33.0%, notably lower than the 48% reported for CARDS patients treated with V-V ECMO in the ELSO registry. Patients who were intubated due to worsening respiratory failure during fa V-V ECMO had significantly higher mortality. Infectious complications, sepsis, and multiorgan failure were the most frequent causes of death. However, significant heterogeneity in the definitions and reporting of management, ECMO-related complications, and outcomes was observed across the papers. Despite the heterogeneity of the data, fa V-V ECMO in CARDS patients can be considered a safe approach associated with a lower mortality rate than that reported in the overall V-V ECMO CARDS population.

• Keywords
• COVID-19-related acute respiratory distress syndrome, awake venovenous extracorporeal membrane oxygenation, barotrauma, bleeding, refusal of intubation,
• Publication type
• Journal Article MeSH
• Review MeSH

Extracorporeal membrane oxygenation (ECMO) is a critical intervention for patients with severe respiratory or cardiac failure, requiring careful management of anticoagulation to prevent thromboembolic complications. This review examines current practices and challenges in ECMO anticoagulation, focusing on strategies, agents, and emerging insights. Unfractionated heparin (UFH) remains the most commonly used anticoagulant, monitored via activated partial thromboplastin time (aPTT) or activated clotting time (ACT). Increasing attention is given to alternative tools like anti-Xa and viscoelastic assays (VEA), which offer potentially more reliable results. Supplementation with antithrombin should be considered if levels fall below 50%-70% to optimize heparin efficacy. Low molecular weight heparin (LMWH) is occasionally used due to its predictable pharmacokinetics, though challenges in dosing and reversal limit its application. Direct thrombin inhibitors, such as bivalirudin, are valuable alternatives, particularly for patients with heparin-induced thrombocytopenia (HIT), though their cost and availability remain barriers. Anticoagulation in ECMO patients is complex, balancing the risks of thrombosis and bleeding. Factors such as patient age, underlying conditions, and ECMO-induced coagulopathies complicate management. Personalized anticoagulation protocols and point-of-care VEA are emerging as effective tools for improving therapy. Routine no-anticoagulation strategies are not recommended unless there are significant bleeding complications. Ongoing research into novel anticoagulants and the long-term impact of anticoagulation on ECMO outcomes is critical. Anticoagulation management in ECMO continues to evolve, focusing on individualized approaches, improved monitoring, and better outcomes. Standardized protocols and further research are essential for optimizing care in this high-risk population.

• Keywords
• Anticoagulation, Argatroban, Bivalirudin, ECMO, LMWH, UFH,
• Publication type
• Journal Article MeSH
• Review MeSH