This secondary analysis of the 2013 United Kingdom National Health Service (NHS) Anaesthesia Activity Survey of the Fifth National Audit Project (of the Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland) shows pediatric anesthesia activity in detail. A local coordinator (LC) in every NHS hospital collected data on patients undergoing any procedure managed by an anesthetist. Questionnaires had 30 question categories. Each LC was randomized to a 2-day period. The pediatric age groups were infants, (<1 year), preschool age (1-5 year), and school age children (6-15 year). The median questionnaire return rate was 98%. The annual caseload was estimated to be 486 900 children: 36 500 infants, 184 700 preschool age, and 265 800 school age children. Almost 90% of children (1-15 year) were ASA 1 or 2 and the substantial majority underwent routine nonurgent ear nose and throat, dental, orthopaedics, or general surgery procedures; 65% were 'day cases'. One in six children were managed outside operating theater sites compared with one in 12 adults. Forty one per cent was in district general hospitals. Almost all ASA 4 and 5 children (89%) and infants (92%) were managed in specialist hospitals. 'Awake' cases and sedation accounted for only 2% of cases. There were notable differences in demography and anesthetic care compared with adults and between different age groups of children. These data enable analysis of the current state of UK pediatric anesthetic practice and highlight differences between pediatric and adult services.

Background: Antibiotic prophylaxis is crucial in head and neck surgery to prevent infection from clean contaminated wounds. Scottish Intercollegiate Guidelines Network (SIGN) guidance, the gold standard of practice, recommends that administration of broad spectrum antibiotics is discontinued after 24 hours post-operation. A three-audit cycle quality improvement project was conducted to assess clinical practice against SIGN guidance at a large London teaching hospital. Methods: Three change initiatives were implemented to improve antibiotic stewardship. First, an update of Trust guidelines with an associated poster campaign to educate staff and improve awareness. Second, introduction of a specific ‘prophylactic antibiotics in head and neck surgery’ bundle on the electronic hospital-wide prescribing system. Third, an update to an antibiotic prescribing guide (Microguide). Results: Over a 3-year study period the number of patients receiving antibiotics beyond 24 hours declined significantly (88% in 2015, 76% in 2016, 25% in 2018), demonstrating improved compliance with SIGN guidelines overall. Despite this, staff documentation of indications for extended antibiotic use remains suboptimal (58% in 2016 and 44% in 2018) as does the number of specimens sent for microbiological analysis (52% in 2016 and 0% in 2018). Conclusions: Appropriate prophylactic antibiotic prescribing can improve morbidity and mortality rates in head and neck cancer patients. Three change initiatives have been demonstrated which can help to improve prescribing compliance in line with SIGN guidance. Ongoing auditing is required to maintain the longevity of improvements made and encourage staff documentation of indications for extended antibiotic use and microbiology specimen analysis.

Explain the factors that are important in determining the type and amount of fluids given to neonates during surgery. Describe the indications and safeguards of blood and blood product administration in the neonate. Recognise the challenges of assessing whether a neonate requires fluids or is fluid replete. Management of fluids in the neonate undergoing major surgery is complex, and is influenced by the gestational age, postnatal age, physiological maturation of organ systems, type of surgery, concomitant illness, and blood loss. In addition, prematurity increases these challenges, as organ systems are immature and body fluid compositions are different to that of a healthy term baby. Much of the evidence is derived from the critically ill neonate; thus, caution must be exercised in extrapolating these data to the neonate undergoing surgery. Neonatal physiology and cardiorespiratory adaptation at birth Changes in body composition and cardiorespiratory adaptation The transition from fetal life to neonatal life involves significant changes in the body water composition, and depends on the gestational age at birth and the stage of cardiorespiratory adaptation (Fig 1). 1 The proportion of extracellular fluid (ECF) is higher in preterm infants and depends on the level of prematurity. Postnatal diuresis Soon after birth, pulmonary vascular resistance decreases dramatically with a consequent increase in blood flow to the lungs and left atrium. This stimulates the production of atrial natriuretic peptide, which in turn stimulates sodium (Na) and water diuresis from the kidneys, and results in a decrease in the ECF volume. This cardiorespiratory adaptation results in a physiological weight loss of 5e10% in term neonates and up to 15% in Anil Visram BSc FRCA is a consultant in paediatric anaesthesia at the Royal London Hospital. He has interests in neonatal fluids and point-of-care testing.

Key Clinical MessagePulmonary function tests such as flow‐volume loops and reconstructive radiological imaging may aid the detection of large airway obstruction prior to corrective surgery for severe scoliosis. Intraoperative use of halo‐gravity traction may help to reduce the severity of the scoliosis, and thus the extrinsic compression or torsion of the airways.