Fibrinolytic Changes in Critical Illnesses: Is Fibrinolysis Shutdown a Specific Concept?

Trauma-induced coagulopathy (TIC) is characterized by dynamic changes in fibrinolysis, which can significantly impact patient outcomes. These changes typically manifest in two phases: hyperfibrinolysis followed by fibrinolysis suppression. In the early stages of TIC, there is often an overwhelming release of tissue plasminogen activator, which leads to excessive fibrinolysis. This hyperfibrinolytic state results in rapid clot breakdown, leading to uncontrolled bleeding and increased mortality. Following the hyperfibrinolytic phase, the fibrinolysis system is suppressed rapidly due to the increased production of plasminogen activator inhibitor-1, leading to fibrinolysis shutdown. This is a state where clot breakdown is significantly reduced, which can contribute to thromboembolic complications and multi-organ failure. Tranexamic acid, a plasmin inhibitor, effectively regulates hyperfibrinolysis as long as it is used in the appropriate hyperfibrinolytic phase. In summary, TIC involves a complex interplay between hyperfibrinolysis and fibrinolysis shutdown, with the balance between these states being crucial for patient survival. Effective management of TIC requires an understanding of these dynamic changes to tailor therapeutic interventions appropriately.