• Hironori Matsumoto, Satoshi Kikuchi, Satoru Murata, Muneaki Ohshita, Yutaka Harima, Suguru Annen, Naoki Mukai, Yuki Nakabayashi, Shirou Ogawa, Mitsuo Okita, Jun Takeba, and Norio Sato.
• Ehime University, Graduate School of Medicine, Department of Emergency and Critical Care Medicine, Toon City, Ehime, Japan.
• Medicine (Baltimore). 2023 Jan 27; 102 (4): e32817e32817.

RationaleVenovenous extracorporeal membrane oxygenation (ECMO) is recommended for the treatment of critically ill patients with acute respiratory distress syndrome due to coronavirus disease 2019 (COVID-19). However, ECMO management can cause both bleeding and thrombotic complications. There are insufficient coagulofibrinolytic data for appropriate ECMO management in patients with COVID-19.Patient ConcernsA 48-year-old man with severe COVID-19-acute respiratory distress syndrome underwent long-term venovenous ECMO management for 48 days. Refractory oronasal bleeding developed on day 13, so the administration of unfractionated heparin was ceased for 29 days.DiagnosisThe patient showed dynamic coagulofibrinolytic responses associated with ECMO management, as shown by fibrin/fibrinogen degradation products, soluble fibrin, thrombin-antithrombin complex, and plasmin-α2-plasmin inhibitor complex elevations, suggesting the development of ECMO-induced coagulopathy.InterventionsWe assessed coagulofibrinolytic markers to decide the appropriate timing for controlling excessive activation of coagulation by exchanging ECMO circuits. Moreover, viscoelastic hemostatic assays were used for adequate transfusion of blood products.OutcomesSafe long-term ECMO management was completed, which was withdrawn on day 48. The patient was weaned off mechanical ventilation on day 57 and was transferred to another hospital for rehabilitation.LessonsMonitoring the coagulofibrinolytic status using markers and viscoelastic hemostatic assays may be effective for safe long-term ECMO management even without anticoagulant therapy.Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.

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