This article presents a comprehensive review and a pragmatic protocol for anticoagulation management in patients undergoing veno-venous extracorporeal membrane oxygenation (V-V ECMO), as practiced in a high-volume ECMO Referral Centre. It underscores the variability in anticoagulation practices among centers, attributed to the lack of high-quality data for personalizing management. The protocol advocates for a tailored approach to anticoagulation and monitoring, utilizing a range of laboratory tests such as anti-Xa, aPTT, ACT, viscoelastic tests, AT levels, platelet count, fibrinogen, and FXIII levels. The goal is to balance the risk of thrombosis and bleeding by personalizing anticoagulation regimens based on a comprehensive evaluation of coagulation status.