Ex-premature infants, before 45 weeks postconceptional age, are at high-risk of apnoea after surgery. General anaesthesia increases the risk of apnoea. We evaluated the tolerance and the efficiency of caudal anaesthesia performed in 25 consecutive conscious ex-premature infants for inguinal herniotomies. N2O/O2 and EMLA cream are used to facilitate caudal puncture. Anaesthesia procedure, patient comfort and complications following the 24 postoperative hours were studied. We report good anaesthesia conditions without compromising the baby's comfort and few perioperative complications. Only two infants with a prior history of apnoea or bronchopulmonary dysplasia had apnoea during and after surgery. A total spinal anaesthesia was the major complication in one infant and prolonged surgery requiring general anaesthesia was the main limitation of this technique in another child. The principal advantage of the procedure is to facilitate and simplify the postoperative management of the babies. The anaesthetic technique does not alter surgical conditions. Caudal epidural anaesthesia performed in awake high-risk preterm infants is beneficial for these infants but requires experienced operators.

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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

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