Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an essential life-support system in critical care specifically engineered to assist cardiac and respiratory function by externally maintaining blood perfusion and oxygenation [1].

However, the invasive nature of VA-ECMO introduces considerable risks, including fatal hemorrhagic complications that primarily result from consumptive coagulopathy, which significantly reduces the fibrinogen concentration [2,3]. These complications often necessitate further invasive procedures, underscoring the critical need for effective coagulation management [4].

The Extracorporeal Life Support Organization guidelines recommend maintaining fibrinogen at ≥150 mg/dL for VA-ECMO patients [5,6], with many institutions using 200 mg/dL as the standard [7]. Despite the guidelines, high-quality research supporting the recommendations is lacking. While one study found that 200 mg/dL fibrinogen does not pose a bleeding risk, the specific fibrinogen levels associated with bleeding risk have not been investigated [8]. Additionally, increased blood product use may worsen outcomes, suggesting a need for more conservative fibrinogen management strategies [9].

This study aimed to explore the association between initial fibrinogen at extracorporeal cardiopulmonary resuscitation (ECPR) initiation and subsequent bleeding complications in VA-ECMO patients following out-of-hospital cardiac arrest.