820 YJ Kim • General considerations and updates in pediatric gastrointestinal diagnostic endoscopy selective. Many factors must be considered, including the patient’s condition, ASA classification, the type of procedure (i.e., diagnostic versus therapeutic), the anticipated level of patient’s cooperation, the parents’ and patient’s preferences, as well as the endoscopist’s experience22). There is consensus that general anesthesia is necessary for complicated therapeutic procedures, patients with neurologic problems, patients at high risk for cardiopulmonary complications, and uncooperative patients who have failed intravenous sedation23). The widespread use of sedation in GIE in children imposes the need for resuscitation and monitoring equipment in the endoscopy room. Standard monitoring must include an electrocardiogram, a blood pressure monitor, and a pulse oximeter. To minimize the adverse reactions, it is recommended to titrate the sedative drugs until the patients are sufficiently sedated. A minimum of 2 assistants are required. One assistant supports the airway, assesses vital signs, and administers medications, while the other assists in biopsies or other endoscopic interventions. A third assistant may be occasionally needed to restrain an agitated child. The endoscopy room must be equipped with pressurized 100% oxygen and additional suction outlets. Resuscitation equipment, including an anesthesia bag with large and small masks, medications, and equipment for airway intubation, and a defibrillator must be immediately available. Postprocedure monitoring Monitoring settings during the procedure are continued, especially for small infants for the next 15-30 minutes, in the recovery room or on the ward. If the patient is sleeping, the patient is placed in the lateral position. If midazolam was used, the child should stay in the ward for a minimum of 2 hours. Amnesia can persist up to 8 hours. Drinks are allowed 1 hour after the end of the endoscopy; special attention is required to avoid choking if topical anesthetic spray was used. The American Academy of Pediatrics has provided discharge criteria as follows24). Cardiovascular function and airway patency are satisfactory and stable. The patient is easily arousable, and protective reflexes are intact. The patient can talk (if age appropriate). For a very young or handicapped child, incapable of the usual expected responses, the presedation level of responsiveness or a level as close as possible to the normal level for that child should be achieved. The state of hydration is adequate. Antibiotic prophylaxis Bacteremia is common following some forms of therapeutic endoscopic procedures, such as dilatation, injection sclerotherapy, or percutaneous endoscopic gastrostomy (PEG), and can occur with diagnostic endoscopy alone. Fortunately, complications resulting from dissemination of endogenous bacteria are uncommon, and infective endocarditis is an extremely rare complication. Furthermore, for most diagnostic and therapeutic procedures, there is scant evidence that antibiotic prophylaxis can reduce the incidence of infective complications. According to the guidelines of the American Heart Association (AH A) and the A merican Society of Gastroenterological Endoscopy (ASGE)25, 26), administration of prophylactic antibiotics is recommended only in select situations. Specific clinical conditions recognized as such are cardiac lesions with high or moderate risk of bacterial endocarditis. Durack27) has established a list of high-, moderate-, and low-risk patients. Prophylactic antibiotics are recommended for high-risk patients (i.e., with prosthetic valve, surgical pulmonary shunt, previous endocarditis, or complex congenital heart disease). In addition to heart diseases, the following are candidates for prophylactic antibiotic therapy: patients with neutropenia; patients with central lines, prosthetic devices, ventriculoperitoneal shunt, and ascites28); and patients on interventional procedures (stricture dilatation, sclerotherapy, PEG29)). Antibiotic recommendations are not standardized, with the ASGE proposing prophylaxis only in high-risk patients. On the other hand, the AHA has recently proposed a simplified regimen for moderate-risk patients. Gram-positive bacteria are the most commonly implicated organisms. In case of cardiac risk, the recommended regimen is as follows30, 31): a combination of ampicillin and gentamicin intravenously or intramuscularly 30 minutes before the procedure. Additional oral amoxicillin 6 hours later or intravenous ampicillin can be used. In patients allergic to penicillin, vancomycin or teicoplanin can replace amoxicillin. The Endoscopy Committee of the British Society of Gastro- enterology recently reported guidelines on prophylactic antibiotic preventions. The guideline states that antibiotic prophylaxis is no longer recommended for the prevention of infective endocarditis in patients with cardiac risk factors who undergo diagnostic or therapeutic endoscopy (Evidence Grade III, Recommendation Grade B). The use of antibiotics is recommended for selected patients with evidence of infections32). Complications Simple diagnostic endoscopy, including mucosal biopsy, confers very few serious complications. The risks of therapeutic endoscopy depend on particular interventions. If performed by a well-trained