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SummaryAllergic reactions to amide local anaesthetic agents are rare. We report the case of a 74-year-old man who suffered anaphylaxis, presenting with cardiovascular collapse, immediately after receiving regional anaesthesia on two separate occasions, the first involving the use of levobupivacaine and the second using ropivacaine. Skin testing revealed positive reactions to both levobupivacaine and ropivacaine, and negative reactions to articaine and lidocaine. Severe allergic reactions can be caused by the amide local anaesthetic drugs, levobupivacaine and ropivacaine. Allergic reactions in local anaesthetics are rare and mostly type IV hypersensitivity reactions involving specific T cells [1]. Immediate allergy to local anaesthetics is extremely rare with only one case of allergy to levobupivacaine [2] and one of allergy to ropivacaine [3] reported. There has been recent criticism of the method for testing of sensitivity to levobupivacaine [4,5] with inadequate information being provided to enable a definitive diagnosis (with the lack of a strongly positive intradermal reaction to a 1:10 000 or even a 1:1000 dilution of levobupivacaine) and a lack of exploration of alternative possible diagnoses. This case report presents a case of immediate-type allergy to amide local anaesthetic agents based on thorough screening. Case reportWe report the case of a 74-year-old man suffering from symptomatic cerebral ischaemia who underwent carotid endarterectomy. On pre-operative assessment, the patient reported no history of allergy to medication or food. He had previously undergone general anaesthesia and local anaesthesia for dental caries without incident.A cervical plexus block was performed with 22 ml levobupivacaine 0.5%, which was delivered by repeat injections. After a few minutes, the patient developed cognitive dysfunction, a convulsive seizure, cutaneous flushing and cardiovascular collapse manifested by a tachycardia to 117 beats.min )1 and hypotension to 80 ⁄ 40 mmHg. This did not respond to intravenous ephedrine (a total of 30 mg was given) nor to phenylephrine administered in repeated boluses (2.7 mg in total was given). Drug overdose was suspected and 250 ml (3 ml.kg ) intravenous 20% lipid was administered immediately, according to French Society of Anaesthesiology and Intensive Care guidelines [6]. The patient's conscious level improved rapidly (Glasgow Coma Scale of 14), as did his cardiovascular instability with his blood pressure rising to 90 ⁄ 57 mmHg. Surgery

Aim: Describing acute respiratory distress syndrome patterns, therapeutics management, and outcomes of ICU COVID-19 patients and to determine risk factors of 28-day mortality. Methods: Prospective multicentre, cohort study conducted in 29 French ICUs. Baseline characteristics, comorbidities, adjunctive therapies, ventilatory support at ICU admission and survival data were collected. Results: From March to July 2020, 966 patients were enrolled with a median age of 66 (interquartile range 58-73) years and a median SAPS II of 37 (29-48). On the first 24 hours of ICU admission, COVID-19 patients received one of the following respiratory supports: mechanical ventilation for 559 (58%), standard oxygen therapy for 228 (24%) and high-flow nasal cannula (HFNC) for 179 (19%) patients. Overall, 721 (75%) patients were mechanically ventilated during their ICU stay. Prone positioning and neuromuscular blocking agents were used in 494 (51%) and 460 (48%) patients, respectively. Bacterial co-infections and ventilator-associated pneumonia were diagnosed in 79 (3%) and 411 (43%) patients, respectively. The overall 28-day mortality was 18%. Age, pre-existing comorbidities, severity of respiratory failure and the absence of antiviral therapy on admission were identified as independent predictors of 28-day outcome. Conclusion: Severity of hypoxaemia on admission, older age (> 70 years), cardiovascular and renal comorbidities were associated with worse outcome in COVID-19 patients. Antiviral treatment on admission was identified as a protective factor for 28-day mortality. Characterising the determinants of outcomes of critically ill COVID-19 patients is crucial to optimise hospital and ICU resources and to provide the appropriate intensity level of care.

IntroductionIcatibant, a first-in-class B2 bradykinin receptor antagonist, appears to have a favorable efficacy and safety profile for the treatment of acute attacks of hereditary angioedema in adults.AimsTo update the evidence and provide an overview of the available data on icatibant.Evidence reviewPeer reviewed articles published and listed in Medline Search and published updated guidelines for the treatment of acute attacks in hereditary angioedema type I and II in adults were reviewed. The validity and quality of evidence were evaluated.Place in therapyClinical evidence for the treatment of acute hereditary angioedema attacks with icatibant is strong. Approximately 10% of the patients require a second dose. No serious adverse reactions have been reported. The only significant side effects consistently registered by 90% of patients are transient local pain, swelling, and erythema at the local injection site.ConclusionSubcutaneously administered 30 mg icatibant has been shown to be a safe and efficacious treatment in clinical trials. It is the only specific treatment authorized for self-administration by the subcutaneous route offering increased patient independence.