Standard anticoagulation protocols for patients with trauma-related acute respiratory distress syndrome (TR-ARDS) undergoing venovenous extracorporeal membrane oxygenation (VV-ECMO) are often inapplicable due to high bleeding risks. This study evaluated the safety and feasibility of a prolonged anticoagulation-free strategy (≥72 h) in patients with severe trauma.

We retrospectively reviewed 37 patients with blunt TR-ARDS at a Level 1 Trauma Center (2016–2024). Patients were categorized into an anticoagulation-free group (withheld ≥72 h; n = 18) and an anticoagulation group (n = 19).

Clinical outcomes, including survival (66.7% vs 68.4%, p = 1.000), VV-ECMO weaning, and hemorrhagic/thrombotic complications, were comparable between groups. Notably, the anticoagulation-free group exhibited significantly higher baseline severity, with lower Glasgow Coma Scale and Trauma and Injury Severity Score scores and more pronounced initial coagulopathy (prolonged PT, lower fibrinogen levels). Despite this, 12 of 18 patients (66.7%) in the anticoagulation-free group successfully completed their entire VV-ECMO course without any systemic anticoagulation, with no increase in circuit-related complications.

Our findings suggest that withholding systemic anticoagulation for ≥72 h is a safe and feasible strategy for high-bleeding-risk trauma patients. This risk-adapted approach, prioritizing hemorrhage control, does not compromise patient safety or device integrity in selected patients with severe trauma and TR-ARDS. Larger multicenter prospective studies should validate this risk-stratified management framework.