The Fibrinolytic System in Bacterial Sepsis: A Comprehensive Review of Current Assessment Methods

Area of Science:

• Sepsis Pathophysiology
• Hemostasis and Thrombosis
• Diagnostic Methods

Background:

• Fibrinolytic impairment is a key factor in sepsis-related hemostasis disturbances, microthrombosis, and organ dysfunction.
• Assessing fibrinolytic activity in sepsis is challenging due to methodological limitations and lack of standardized methods.
• Current focus on coagulation activation overlooks critical fibrinolytic processes.

Purpose of the Study:

• To comprehensively review current methods for assessing fibrinolytic activity in bacterial sepsis.
• To examine the clinical applications, strengths, and limitations of existing assessment techniques.
• To explore future perspectives for improved diagnostic approaches in sepsis.

Main Methods:

• Systematic literature search identifying 52 relevant studies.
• Inclusion of observational cohorts examining fibrinolysis assessment in adult sepsis patients.
• Analysis of biomarkers, global plasma tests, and whole-blood viscoelastic testing.

Main Results:

• Early fibrinolytic shutdown, driven by plasminogen activator inhibitor-1 (PAI-1), correlates with sepsis severity and mortality.
• Methods include PAI-1, D-dimer, clot lysis time, plasmin generation assays, and viscoelastic tests (ROTEM, TEG).
• Modified viscoelastic tests show promise for detecting fibrinolytic resistance, but standardization and routine implementation are lacking.

Conclusions:

• Fibrinolytic assessment offers crucial prognostic information in sepsis despite current challenges.
• Point-of-care viscoelastic testing with modified protocols presents a promising avenue for real-time evaluation.
• Future research should prioritize standardized, automated assays for routine clinical practice and personalized sepsis therapy.