Sepsis-induced coagulopathy: advancing from static indicators to dynamic stratification in diagnosis and treatment

Sepsis-induced coagulopathy (SIC) is a critical intermediate stage in the progression from sepsis to disseminated intravascular coagulation (DIC), characterized by an imbalance between coagulation activation and fibrinolysis inhibition, with widespread formation of microthrombi as a core feature. The incidence of SIC exceeds 60%, and its mortality rate is as high as 30%. In this article, we systematically review 4 major issues in current research on the diagnosis and treatment of SIC: ① For assessment and intervention of platelet function, introducing various platelet function tests, along with controversies in antiplatelet and pro-platelet therapies; ② In mechanisms and evaluation of altered fibrinolysis, elaborating the fibrinolysis inhibition caused by plasminogen activator inhibitor-1 (PAI-1) overexpression and the associated detection dilemmas; ③ About issues and optimization of SIC diagnostic criteria, comparing the International Society on Thrombosis and Haemostasis (ISTH)-SIC criteria, modified Chinese SIC criteria, and the 2025 ISTH-DIC criteria, pointing out shortcomings such as insufficient specificity, exclusion of D-dimer, and susceptibility of prothrombin time-international normalized ratio (PT-INR) to interference, and proposing optimization strategies including dynamic scoring, individualized thresholds, novel molecular biomarkers, and machine learning; ④ Concerning precision anticoagulation strategies, emphasizing the importance of anticoagulation timing, drug selection, and dynamic monitoring [e. g., anti-activated factor X (Xa) activity, thromboelastography], and analyzing the application of heparin, low molecular weight heparin, nafamostat, and other agents. SIC patients frequently face dual risks of bleeding and thrombosis, which can rapidly shift. Clinical management should move beyond conventional static indicators, integrate immunothrombosis mechanisms, novel molecular biomarkers [e. g., thrombin-antithrombin complex (TAT), plasmin-α2-plasmin inhibitor complex (PIC), soluble thrombomodulin (sTM)] and dynamic monitoring technologies to seize the “therapeutic window” for anticoagulation, and implement stratified management and precision diagnosis and treatment based on individualized, multidimensional assessment.