Complex immune response to infection has been highlighted, more than ever, during the COVID-19 pandemic. This review explores the immunomodulatory treatment of moderate-to-severe forms of this viral sepsis in the context of specific immunopathogenesis. Our objective is to analyze in detail the existing strategies for the use of immunomodulators in COVID-19. Immunomodulating therapy is very challenging; there are still underpowered or, in other ways, insufficient studies with inconclusive or conflicting results regarding a rationale for adding a second immunomodulatory drug to dexamethasone. Bearing in mind that a “cytokine storm” is not present in the majority of COVID-19 patients, it is to be expected that the path to the adequate choice of a second immunomodulatory drug is paved with uncertainty. Anakinra, a recombinant human IL-1 receptor antagonist, is a good choice in this setting. Yet, the latest update of the COVID-19 Treatment Guidelines Panel (31 May 2022) claims that there is insufficient evidence to recommend either for or against the use of anakinra for the treatment of COVID-19. EMA’s human medicines committee recommended extending the indication of anakinra to include treatment of COVID-19 in adult patients only recently (17 December 2021). It is obvious that this is still a work in progress, with few ongoing clinical trials. With over 6 million deaths from COVID-19, this is the right time to speed up this process. Our conclusion is that, during the course of COVID-19, the immune response is changing from the early phase to the late phase in individual patients, so immunomodulating therapy should be guided by individual responses at different time points.

Immune cells and mediators play a crucial role in the critical care setting but are understudied. This review explores the concept of sepsis and/or injury-induced immunosuppression and immuno-inflammatory response in COVID-19 and reiterates the need for more accurate functional immunomonitoring of monocyte and neutrophil function in these critically ill patients. in addition, the feasibility of circulating and cell-surface immune biomarkers as predictors of infection and/or outcome in critically ill patients is explored. It is clear that, for critically ill, one size does not fit all and that immune phenotyping of critically ill patients may allow the development of a more personalized approach with tailored immunotherapy for the specific patient. In addition, at this point in time, caution is advised regarding the quality of evidence of some COVID-19 studies in the literature.

SARS-CoV-2 virus causes COVID-19, which is characterized by a high level of aerosol spreading of viral particles. Aerosol generating procedures are high-risk procedures for anesthesiologists and necessities expensive high level protective personal equipment (PPE) (level 3). The problem with COVID-19 is the high number of patients, which presents an economic burden for the health care system and country, and causes issues with human and equipment resources. Airway protocols vary among hospitals like three gloves technique, videolaryngoscope, FFP3 masks, eye protection, and additional shield. All parts of the anesthesiologist's body need to be covered with protective equipment. Extubation is also considered as high risk from the point of aerosol production, and PPE level 3 is required. Patient monitoring for early warning signs leads to intubation, which is predicted and planned. The patient is preoxygenated, fully relaxed, without mask ventilation as rapid sequence intubation. The suggested time for intubation is 30 s, immediate cuff inflation, followed by a tube connecting with the machine for mechanical ventilation. Capnography serves for the tracheal intubation confirmation. Supraglottic devices and cryccothyteothomy are reserved for situation can't intubate-can't oxygenate. Airway procedures are considered as high-risk procedure, and the most experienced anesthesiologist should perform them in the shortest possible time. The best solution is to have an airway dedicated team, educated in simulation center for this specifiec type of intubation, proper planning, prepared and checked medications and equipment.

Introduction: Acute mesenteric ischemia (AMI) in cardiac surgery is a rare condition, associated with low incidence (0.2-0.4%) and very high mortality (up to 95%). Advanced age and coexisting morbidity, such as acute myocardial infarction or atrial fibrillation are the known risk factors. Case report: We are presenting 76 years old patient with aortic valve replacement and double coronary artery bypass grafting followed by hemodynamic instability and lactic acidosis on the first postoperative day. Diagnosis of AMI was made by exclusion. We discuss diagnostic and therapeutic approach applied regarding existing data from the literature. Conclusion: Diagnosis of AMI after cardiac surgery demands high level of suspicion. Early diagnosis is of vital importance. Systematical approach and early surgical exploration affects the overall outcome.

Introduction: Transurethral resection of the prostate (TURP) syndrome is iatrogenic state of water intoxication after transurethral resection of the prostate, an endoscopic procedure in urology. Neurological changes, heart failure and respiratory failure, followed with hyper or hypotension and hypoxia and acidemia, are dominant signs in clinical presentation of the TURP syndrome. For the last decade, better understanding of TURP syndrome pathophysiology and development of preventive measures, led to decrease incidence of the TURP syndrome. The present incidence of TURP syndrome is below 1 %. Case report: We are presenting case of severe TURP syndrome developed during endoscopic two hours long urologie procedure. TURP syndrome was manifested with serious neurologic disturbance which has expanded to coma and epileptic seizures, followed with hemodynamic instability requiring inotropic and vasopressor support. Severe hyponatremia (serum Na+102 mmol/l) was dominant biochemical finding. We are presenting therapy approach to the patient with severe form of TURP syndrome followed by patient health condition improvement. Conclusion: TURP syndrome is iatrogenic potentially life threatening condition, which may be presented during or after intervention. With constant patient monitoring symptoms of TURP syndrome can be early recognized and with adequate therapy potential complications can be avoided.