CONTINUING EDUCATION

Special Needs Populations:

Perioperative Care of the
Child With Epilepsy
RACHAEL KUBISKI, MS, RN-BC, CNRN 2.2
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Purpose/Goal
To educate perioperative nurses about caring for children
with epilepsy who are undergoing surgery.
Objectives
1. Describe epilepsy.
2. Identify factors that may trigger seizures.
3. Identify adverse effects of medications used to treat epilepsy.
4. Explain treatment options for children with epilepsy.
5. Discuss nursing care of children with epilepsy who are
undergoing surgery.
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AORN is accredited as a provider of continuing nursing edu-
cation by the American Nurses Credentialing Centers Com-
mission on Accreditation.
This program meets criteria for CNOR and CRNFA recertifi-
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AORN is provider-approved by the California Board of
Registered Nursing, Provider Number CEP 13019. Check
with your state board of nursing for acceptance of this activ-
ity for relicensure.
Conflict of Interest Disclosures
Ms Kubiski has no declared affiliation that could be per-
ceived as posing a potential conflict of interest in the publi-
cation of this article.
The behavioral objectives for this program were created
by Rebecca Holm, MSN, RN, CNOR, clinical editor, with
consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Holm and Ms Bakewell have
no declared affiliations that could be perceived as posing
potential conflicts of interest in the publication of this
article.
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No sponsorship or commercial support was received for this
article.
Disclaimer
AORN recognizes these activities as continuing education
for registered nurses. This recognition does not imply that
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proves or endorses products mentioned in the activity.

doi: 10.1016/j.aorn.2012.02.006
AORN, Inc, 2012 May 2012 Vol 95 No 5 AORN Journal 635
SPECIAL NEEDS POPULATIONS
Perioperative Care of the
Child With Epilepsy
RACHAEL KUBISKI, MS, RN-BC, CNRN
E
pilepsy, a chronic condition in which sei-
zures occur, is a neurological disease that
affects approximately two million people
in the United States.1 According to the Centers
for Disease Control and Prevention, 140,000 new
cases are reported each year, mainly affecting
children and older adults.1 Despite being the third
most common neurological diagnosis, epilepsy
remains one of the least understood of major
chronic conditions.2 Using data from the Bureau
of Labor Statistics, the Centers for Disease Con-
trol and Prevention estimates that the direct and
indirect cost of epilepsy is $15.5 billion.1 The
cost of epilepsy is also high in terms of disability
and human costs, including reproductive issues,
comorbid disorders such as cerebral palsy and
autism, increased incidence of depression, and
discrimination against people with epilepsy be-
cause of employers fears and misinformation
about epilepsy.3
In children, the potential for long-term neuro-
logical, behavioral, and cognitive problems may
significantly affect the quality of their lives.3 The
purpose of this article is to provide the reader
with a brief overview of epilepsy and currently
available treatment modalities. In addition, special
considerations for perioperative patients with epi-
lepsy are addressed, including potential interac-
tions with various anesthetic agents.
POTENTIAL CAUSES OF EPILEPSY
Epileptogenesis is a process that causes abnormal
firing of neurons because of chemical and electri-
cal malfunctions, which results in a seizure.3 The
National Institute of Neurological Disorders and
636 AORN Journal May 2012 Vol 95 No 5
2.2
www.aorn.org/CE
Stroke states that although there are many
causes of epilepsy (eg, genetics, prenatal injury,
poisoning, head injury, brain tumors, infections,
Alzheimer disease), approximately 50% to
70% of all epilepsy diagnoses have no identifi-
able cause.4 Alcohol, lack of sleep, hormonal
changes, and stress may trigger a seizure in
someone who is susceptible; however, these
factors do not cause epilepsy.4
For many years, the scientific community ne-
glected the effects of genetics on epilepsy; how-
ever, interest in the role of genetics was reinvigo-
rated by Lennox around 1960.5 His emphasis was
on the multifactorial nature of epilepsy. Lennox
believed that the threshold for seizures was influ-
enced by complex interactions between genes and
environment.5 The role of genetics in idiopathic
epilepsy continues to be elusive.5
The National Institute of Neurological Disor-
ders and Stroke and other federal agencies are
involved in several areas of research to identify
how to prevent, treat, and cure epilepsy.3 The
Epilepsy Phenome/Genome Project is just one of
the projects supported by the National Institute of
Neurological Disorders and Stroke to discover a
connection between genes and epilepsy.3
CLASSIFICATION OF SEIZURES
Intractable seizures are experienced by approxi-
mately 25% to 30% of patients with epilepsy de-
spite medications and surgery.4 Status epilepticus,
a seizure lasting longer than five minutes or a
cluster of seizures without recovery of conscious-
ness, and sudden unexplained death in epilepsy
(SUDEP) are two life-threatening conditions for
AORN, Inc, 2012
SPECIAL NEEDS POPULATIONS
which the patient with epilepsy is at special risk.6
The risk of SUDEP is increased in patients with
poorly controlled seizures, those who require mul-
tiple antiepileptic medications, and patients who
have a long-term diagnosis of chronic epilepsy.6
The process of classifying seizures began in
the 1960s and has been continually evolving
with many revisions by the International League
Against Epilepsy.7 The earliest attempts at clas-
sification failed to distinguish the age at onset
and epilepsy of infancy and the resultant prog-
nosis.7 The 1989 classification by the Interna-
tional League Against Epilepsy is widely con-
sidered to be the best tool for pediatric epilepsy
and epilepsy syndromes.8
A single seizure does not mean that a patient
has epilepsy. A diagnosis of epilepsy requires that
the patient has experienced two or more unpro-
voked seizures without an identifiable cause.9 Ep-
ilepsy syndromes are defined as
an epileptic disorder characterized by a cluster of
signs and symptoms customarily occurring to-
gether; these include such items as type of sei-
zure, etiology, anatomy, precipitating factors, age
of onset, severity, chronicity, diurnal and circa-
dian cycling, and sometimes prognosis . . . a syn-
drome does not necessarily have a common etiol-
ogy and prognosis.10(p389)
The three main categories of seizures are:
focal (ie, with or without impairment in
consciousness),
generalized (ie, convulsive or nonconvul-
sive), and
11
unclassified epileptic seizures (Table 1).
TREATMENT OF EPILEPSY
There are many treatment options available for
patients with epilepsy. Treatment options include
antiepileptic medications, surgery, and diet.
Medications
The goal of medication therapy is to provide
optimal seizure control while eliminating ad-
verse effects.12 Monotherapy (ie, controlling
www.aornjournal.org
seizure activity with one antiepileptic medica-
tion) is preferred; however, many patients will
not respond favorably or will experience intol-
erable adverse effects to the first antiepileptic
medication attempted.12 In addition, many pa-
tients do not experience relief from seizures
with one medication and, as a result, are pre-
scribed several different medications. Although
many medications are available, both old and
new, almost all have the potential for serious cog-
nitive, psychosocial, and even life-threatening
adverse effects. The choice of which antiepilep-
tic medication is used needs to be carefully
considered, taking into account
individual circumstances,
ease of dosing,
severity of seizures,
seizure type,
interactions with other medications, and
underlying medical conditions and
comorbidities.
Ultimately, the choice should be based on what is
best for the patient and which medication will
have the greatest effect on quality of life while
providing optimal seizure control.13
Treatment of patients who have a history of
seizures must be carefully managed. Many of
these patients are on multiple antiepileptic med-
ications, many of which have adverse hemato-
logic effects. For example, ethosuximide, an
older antiepileptic medication, may cause leu-
kopenia. Newer antiepileptic medications that
also may cause leukopenia are gabapentin, leve-
tiracetam, and felbamate. In addition, levetirac-
etam may decrease hemoglobin, hematocrit, and
red blood cell count. Felbamate also has the
potential to cause thrombocytopenia, as do the
older antiepileptic medications valproic acid
and carbamazepine. Valproate acid also in-
creases bleeding time. Pediatric patients taking
zonisamide are at increased risk for metabolic
acidosis if they are on the ketogenic diet or are
having surgery.14
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TABLE 1. Categories of Seizures1-3

Focal (formally referred Focal: consciousness is not impaired.

to as partial or local) Origin of localization is either anatomic or functional.

Clinical presentation is dependent on the area of the brain that is involved (eg,

occipital lobe onset will cause visual disturbances).

Symptoms include

motor (eg, twitching, jerking),

somatosensory or special (eg, tingling, numbness),

autonomic (eg, flushing, pupillary dilation), and

psychic (eg, feeling of dj vu, illusions).

Complex focal: consciousness is impaired.

Origin of localization is either anatomic or functional.

Patients frequently experience an aura, the form of which is dependent on the area

of seizure focus.
Patients frequently experience automatisms (eg, eye blinking, lip smacking).

Patients may experience post-ictal confusion.

Focal with secondary generalization

Focal onset that spreads to other areas of the brain.

Any seizure has the potential to generalize.

Generalized (convulsive or Typical absence

nonconvulsive) Involves both hemispheres.

Consciousness is impaired or lost.

Brief onset and recovery.

Patients are briefly unaware of their surroundings and have no memory of the

event.
Eye blinking and other automatisms are more common.

Patients may experience multiple seizures per day, typically lasting less than 10

seconds.
May be misinterpreted as daydreaming.

An electroencephalogram is necessary for correct diagnosis.

Atypical absence
Involves both hemispheres.

Consciousness is impaired or lost.

Onset and recovery are not as abrupt as in typical absence.

Duration is usually longer than typical absence.

Significant likelihood of tonic or myoclonic activity or decreased postural tone.

Onset occurs before age five years and is often associated with mental retardation.

Tonic-clonic, myoclonic, clonic, tonic, atonic seizure

Involves both hemispheres.

Consciousness is impaired or lost.

Motor involvement is bilateral.

Involves entire body.

Unclassified All seizures that do not fit into one of the other two categories because of incomplete
or inadequate data (eg, certain types of neonatal seizures).

1. Nordli DR. Classifications of epilepsies in childhood. In: Pellock JM, Bourgeois BF, Dodson WE, eds. Pediatric Epilepsy Diagnosis and Therapy. 3rd ed.
New York, NY: Demos Medical Publishing; 2008:137-146.
2. Pearl PL, Holmes GL. Childhood absence seizures. In: Pellock JM, Bourgeois BF, Dodson WE, eds. Pediatric Epilepsy Diagnosis and Therapy. 3rd ed.
New York, NY: Demos Medical Publishing; 2008:323-334.
3. Kotagal P. Localization-related epilepsies: simple partial seizures, complex partial seizures, and Rasmussen syndrome. In: Pellock JM, Bourgeois BF,
Dodson WE, eds. Pediatric Epilepsy Diagnosis and Therapy. 3rd ed. New York, NY: Demos Medical Publishing; 2008:377-385.

638 AORN Journal

SPECIAL NEEDS POPULATIONS
Surgical Options
Surgical resection for intractable seizures can pro-
vide significant reduction in seizure activity.15
The surgical procedures most commonly used are
temporal lobe resection, corpus callosotomy, and
hemispherectomy. Some types of epilepsy sur-
gery, including hemispherectomy, have the poten-
tial to completely eliminate seizures in certain
patient populations. The most significant success
has been in patients with partial epilepsy that
is caused by a lesion in the temporal lobe.16
In a study involving 15 children performed by
Hudgins et al,17 10 patients with focal cortical
dysplasia were seizure free on four-year follow-
up after surgery. In patients for whom surgical
resection is appropriate, the surgery should be
performed emergently to prevent further neuronal
damage.18
Corpus callosotomy is considered a palliative
surgery and is not curative. Typically, corpus cal-
losotomy is reserved for patients with tonic and
atonic seizures who are at high risk for injury
related to their seizure activity.18 Patients who
undergo successful surgery for epilepsy, which
either eliminates seizure activity altogether or sig-
nificantly reduces the number of seizures, also
have the advantage of improved psychological
function and quality of life.15
For patients with intractable epilepsy who are
not candidates for surgical resection, vagal nerve
stimulation (VNS) is an option. The vagal nerve
is named for the Latin term for wanderer because
the vagal nerve wanders throughout the head, tho-
rax, and abdominopelvic regions.16 Since VNS
was first approved by the US Food and Drug Ad-
ministration in 1997, more than 15,000 patients
have undergone this procedure, which typically is
performed in an outpatient setting.15 The exact
way in which VNS provides seizure relief is not
known, but several studies have shown as much
as a 50% reduction in seizure activity over time
with VNS.18 In addition to reducing seizure fre-
quency, children with an implanted vagal nerve
stimulator have the added benefit of improved
www.aornjournal.org
independence, learning, and mood.18 Typically,
VNS is used in patients with partial seizures, al-
though its use is increasing for patients with gen-
eralized seizures.
Ketogenic Diet
The ketogenic diet is another treatment option for
intractable seizures that do not respond to medica-
tions and for patients who are not surgical candi-
dates. The diet includes high fat, low carbohy-
drates, low protein, and fluid restrictions. The
typical ratio is 4:1, which means that 90% of the
diet consists of fat from oils, butter, cream, and
mayonnaise. The remaining 10% of the diet is
from carbohydrates and protein combined and
includes fruits and vegetables. The protein com-
ponent is from high biological sources (eg, poul-
try, meats, fish, dairy, soy), which is important
because protein is needed for growth.19 The pur-
pose of this diet is to keep the patient in a state
of therapeutic ketosis, which produces the meta-
bolic response associated with fasting. This re-
sponse causes the body to use free fatty acids
rather than glucose for energy.19 The ketogenic
diet can be curative in many patients. Patients
who do not experience elimination of seizures
may still have a significant reduction in the sever-
ity and number of seizures. Another important
benefit is discontinuation of or reduction in anti-
epileptic medications, which leads to improved
awareness, alertness, and responsiveness.19
CHILDREN WITH EPILEPSY UNDERGOING
UNRELATED SURGERY
Children with epilepsy undergo surgery for a vari-
ety of reasons not related to their epilepsy. Many
of these patients take multiple medications be-
cause of the intractable nature of their epilepsy.
Generally, it is recommended that patients con-
tinue their antiepileptic medications up to the time
of surgery and resume them as soon as possible
after surgery.9 As for all patients, safety in the
preoperative, intraoperative, and postoperative
periods must be a priority. Many children with
epilepsy also have cognitive, psychosocial, and
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May 2012 Vol 95 No 5 KUBISKI

behavioral issues as a result of frequent seizures as simple as listening to their teddy bear or
or their medications, and these children may re- dolls heart before listening to the childs heart or
quire additional preoperative preparation time. allowing the child to listen to his or her own
heart first. Using dolls is also helpful for illustrat-
Preoperative Considerations ing care procedures such as ostomy and gastric
Unlike a patient with a cardiac condition, a tube care before performing them on the child.
patient with epilepsy cannot be cleared for Caring for a child with a disability often requires
surgery (R. Cheng, MD; oral communication, the nurse to vary his or her routine to meet the
August 28, 2011). The unpredictable nature of special needs of the child, taking into consider-
epilepsy is one of the significant challenges in ation that the childs developmental age may be
caring for a patient with a history of seizures. very different from his or her chronological age.
Stress, lack of sleep, anxiety, and NPO status For example, using a doll would be appropriate
all have the potential to lower the seizure for a child who has a chronological age of 14
threshold in patients, and anticipating surgery years but who developmentally is at the level of a
could be a major stressor for children with a six year old. For older children and adolescents,
diagnosis of epilepsy. The preoperative nurse books with illustrations or videos may be more
must develop an individualized plan of care to appropriate than play to help them understand the
guide the management of the patient during the care and treatments being provided.
entire perioperative period, based on compre-
hensive assessment data that address all com- Intraoperative and Anesthetic
monly coexisting conditions (Table 2). Considerations
Nurses caring for pediatric patients need to Treating the patient with epilepsy requires the
understand growth and development and the im- perioperative team to be aware of the potential
portance of play in creating a safe environment. effects of anesthetic medications and their interac-
Incorporating play into the care of a child can be tion with seizure medications. Antiepileptic medi-
cations may interact with anesthetic medications
by changing the pharmacoki-
netics of the anesthesia med-
AORN Resources ications as a result of their
adverse effects on enzyme
Clinical Answers: Medication Administration. induction or inhibition. Sev-
http://www.aorn.org/Clinical_Practice/Clinical_Answers/ eral medications used for
Clinical_Answers.aspx. general anesthesia have pro-
AORN Video Library: Preparing Children for Surgery convulsant properties, anti-
(Cin-Med, 1991). http://cine-med.com/index.php?navaorn. convulsant properties, or
Periop Modules: Medications and Solutions. http://www.aorn
both and may need to be
.org/PeriopModules/. avoided if possible.9
Periop Modules: Patient and Family Education. http://www
Sevoflurane is a newer
.aorn.org/PeriopModules/. anesthetic agent that should
Recommended practices medication safety. In: Perioperative
be avoided in most patients
Standards and Recommended Practices. Denver, CO: AORN,
with a history of seizures
Inc; 2012:251-300.
because it has the potential to
Web site access verified February 16, 2012. produce epileptiform activity
on electroencephalography

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SPECIAL NEEDS POPULATIONS www.aornjournal.org

TABLE 2. Perioperative Nursing Implications: Children With Epilepsy

Preoperative care
Schedule procedures for children early in the day to decrease fasting time.
Establish a therapeutic relationship with the child and caregiver.
Provide a safe and calm environment, recognizing the cognitive, psychosocial, and behavioral implications of children with a
history of epilepsy.
Ensure seizure precautions are available at the bedside (eg, bag/mask, suction, oxygen, padded side rails).

Ensure immediate access to rescue medications (eg, lorazepam, diazepam IV, diazepam rectal gel).

Obtain a relevant history, including

the childs age at seizure onset;

a detailed description of the childs seizure activity, including auras;

precipitating factors and known factors that lower the childs seizure threshold;

the date of the last seizure;

all seizure medications, including rescue medications, and the route, frequency, dose, date, and time of the last dose of

each medication;
history of apnea, obstructive sleep apnea, loud snoring, or medication-induced hypoventilation;

the presence of a vagal nerve stimulator, if applicable;

dietary restrictions (eg, if the child is on a ketogenic diet, do not use syrup-based oral medications or IV fluids containing

carbohydrates);
all laboratory values (eg, for hematologic conditions), including antiepileptic medication levels; and

the presence of comorbidities (eg, obesity, depression).

Obtain baseline vital signs on the day of surgery.

Obtain baseline data regarding the childs developmental age and impairment in cognitive, psychosocial, and behavioral
skills.
Perform a medication reconciliation and obtain the childs history of allergies.
Ensure that the child took his or her antiepileptic medications before surgery.
Establish IV access before arrival in the OR suite if possible, depending on the childs psychosocial and behavioral
impairment.
Administer prophylactic antibiotics.
Enforce practice guidelines governing infection control and prevention.
Encourage family members to participate by giving the child his or her medications, encouraging the child to communicate
with staff members, and providing comfort measures during invasive procedures.
Incorporate the childs routine in the plan of care.
Use visual aids and play therapy when communicating with the child.
Prepare the childs family members for a longer-than-usual observation period after surgery.

Intraoperative care
Provide a safe and calm environment, recognizing the cognitive, psychosocial, and behavioral implications of children with a
history of epilepsy.
Maintain seizure precautions.

Communicate a description of the childs seizure activity and the date of the last seizure to the OR team.

Communicate antiepileptic medications and levels.

Communicate any history of apnea or loud snoring.

Communicate the use of vagal nerve stimulator or a ketogenic diet.

Ensure maintenance of ketosis, if applicable.

Establish IV access if this was not possible preoperatively.
Continuously monitor the child for seizure activity.
Observe for adverse effects from anesthetics, sedatives, or analgesics.
(continued)

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TABLE 2. (continued) Perioperative Nursing Implications: Children With Epilepsy

Postoperative care
Provide a safe and calm environment, recognizing the cognitive, psychosocial, and behavioral implications of children with a
history of epilepsy.
Maintain IV access.

Maintain the airway and monitor the child for signs of obstruction or respiratory depression.

Monitor the child continuously for seizure activity.

Monitor the childs hematologic status.

Ensure immediate access to rescue medications if needed.

Make clinical judgments regarding pain control based on cues and information from the childs family members.
Communicate with the child who has sensory impairment to prevent feelings of isolation.
Update the family members on the childs condition and allow family members to be with the child in the postanesthesia
care unit as soon as this is safe and practical.
Provide a favorite toy or other objects of comfort.
Provide discharge instructions to the childs family members based on the interdisciplinary plan of care.
Ensure that the child resumes taking his or her antiepileptic medications as soon as possible after surgery.

during inhalation in both pediatric and adult patients
who do not have a history of seizures.16 Sevoflurane
also has been reported to be responsible for both
focal and generalized seizures in patients with and
without a history of seizures as they are emerging
from anesthesia.20 Other instances of sevoflurane-
induced seizures have been reported. Two case re-
ports by Akeson and Didriksson21 described seizure
activity in a healthy three-year-old child with no
history of seizures and a four-year-old child with a
family history of seizures after anesthesia using
sevoflurane. Rewari and Sethi22 reported that sevo-
flurane has the potential to lower the seizure thresh-
old in patients who have febrile convulsions, intra-
cranial pathology, and hyperventilation as well as
epilepsy. Sevoflurane may be a popular choice for
pediatric patients because it has a pleasant odor and
low solubility in blood; however, given its proclivity
to be proconvulsant, its use should be carefully con-
sidered or avoided in any patient with a history of
seizures.23 Enflurane has also been shown to pro-
duce electroencephalographic changes in the pediat-
ric patient, and alternative medications should be
selected if possible.24 Etomidate,16 ketamine,25 and
methohexital26 are other anesthetic agents that have
the potential to induce seizures in patients or lower
the seizure threshold in patients with a history of
epilepsy and should also be avoided.
There are special anesthesia considerations for
surgical patients who are on the ketogenic diet.
The ketogenic diet is only effective if the patient
remains in a state of therapeutic ketosis. The
acid-base balance is also modified by the keto-
genic diet, and maintaining both ketosis and mod-
ified acid-base balance is vital for preventing
seizures during the perioperative period.27 For
pediatric patients, it is common to use oral pre-
medications and to disguise their unpleasant taste
with flavored syrup. The use of sweetened syrups
is contraindicated in a patient on the ketogenic
diet because the carbohydrates and amino acids in
the syrups will cause the ketone levels to drop
and the patient will no longer be in ketosis. The
use of IV fluids containing amino acids and car-
bohydrates is contraindicated for the same reason.
Monitoring the patients acid-base balance
throughout the perioperative period is necessary
because ketone bodies may cause metabolic aci-
dosis, which decreases the seizure threshold.
Propofol may be a safer choice for anesthesia
than a high concentration of sevoflurane in inh-
alation induction because of the potential of

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SPECIAL NEEDS POPULATIONS
sevoflurane to illicit seizure activity. However,
patients on the ketogenic diet depend on optimal
liver function as their energy source.27 Many anti-
epileptic medications are metabolized through the
liver, as is propofol, so maintenance of general
anesthesia with sevoflurane may be preferred in
patients on the ketogenic diet.27
Postoperative Considerations
Patients with refractory seizures are at increased
risk for symptoms of obstructive sleep apnea; ap-
proximately one-third of this patient population
has obstructive sleep apnea along with other co-
morbidities.24 The occurrence of obstructive sleep
apnea may be related to chronic antiepileptic
medication therapy and medication-induced hy-
poventilation, obesity as an adverse effect of
medication, and seizures that occur during
sleep.28 In addition, patients with a vagal nerve
stimulator may have depressed postoperative re-
spiratory efforts and increased obstructive airway
complications as a result of chronic stimulation of
the vagal nerve.24 They are also at increased risk
for severe postoperative apnea caused by the
combined effects of VNS and the respiratory de-
pressant effects of opioids.24
It is important for the postanesthesia care
unit nurse to be familiar with the type and de-
scription of seizures the patient has. Patients
often shiver after general anesthesia or experi-
ence dystonic movements, and this should not
be mistaken as seizure activity.9 However, it is
crucial that true seizure activity be recognized
and treated appropriately.
CHALLENGES OF CARING FOR
CHILDREN WITH EPILEPSY
Caring for children with a history of epilepsy has
many challenges because many of these children
also have significant comorbidities and develop-
mental delays. One of the most common comor-
bid conditions, based on epidemiological studies,
is depression.15 The cognitive, psychosocial, and
behavioral problems these children exhibit are
considerable, which increases stress on the family
www.aornjournal.org
unit. Not surprisingly, parents response to their
childs epilepsy is closely correlated with the psy-
chosocial care needs of the child.29 A childs in-
ability to cope with the uncertainties of epilepsy
is often influenced by maladaptive behaviors in
the family, which can increase the childs psycho-
social dysfunction.30 The unpredictability of
seizures further complicates the treatment of pa-
tients with a history of epilepsy who are undergo-
ing surgery. The parents and caregivers of chil-
dren with epilepsy often are overprotective, have
higher levels of anxiety, and are reluctant to dis-
cipline their children.29 Nurses should be sensi-
tive to the fears of both the child and caregiver
and refrain from judgment if the child is acting
out. Allowing the caregivers to stay with the child
as long as possible and including caregivers in the
care of the child will go a long way toward alle-
viating the stress of surgery.24
References
1. What is the burden of epilepsy in the United States?
Centers for Disease Control and Prevention. http://
www.cdc.gov/epilepsy/basics/faqs.htm#4. Accessed
December 19, 2011.
2. About epilepsy. Epilepsy Foundation. http://www
.epilepsyfoundation.org/aboutepilepsy/index.cfm. Ac-
cessed December 19, 2011.
3. Curing epilepsy: the promise of research. National In-
stitute of Neurological Disorders and Stroke. http://
www.ninds.nih.gov/disorders/epilepsy/epilepsy_
research.htm. Accessed December 19, 2011.
4. Seizures and epilepsy: hope through research. National
Institute of Neurological Disorders and Stroke. http://
www.ninds.nih.gov/disorders/epilepsy/detail_epilepsy
.htm#187173109. Accessed December 19, 2011.
5. Shorvon S. Heredity in epilepsyan historical over-
view. Neurology Asia. 2011;16(Suppl 1):5-8.
6. SUDEP (sudden unexpected death in epilepsy). Epi-
lepsy Foundation. http://www.epilepsyfoundation.org/
aboutepilepsy/healthrisks/sudep/index.cfm. Accessed
December 19, 2011.
7. Troester M, Rekate HL. Pediatric seizure and epilepsy
classification: why is it important or is it important?
Semin Pediatr Neurol. 2009;16(1):16-22.
8. Engel J Jr. ILAE classification of epilepsy syndromes.
Epilepsy Res. 2006;70(Suppl 1):S5-S10.
9. Gratnix AP, Enright SM. Epilepsy in anaesthesia and
intensive care. Contin Educ Anaesth Crit Care Pain.
2005;5(4):118-121.
10. Proposal for revised classification of epilepsies and epi-
leptic syndromes. Commission on Classification and
Terminology of the International League Against Epi-
lepsy. Epilepsia. 1989;30(4):389-399.
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11. Nordli DR. Classifications of epilepsies in childhood.
In: Pellock JM, Bourgeois BF, Dodson WE. Pediatric
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lepsy, Part 2: Epilepsy surgery and vagus nerve stimu-
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644 AORN Journal
KUBISKI
23. Rothrock JC. Anesthesia. In: DeLamar LM, ed. Alexan-
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induced seizures. Internet J Anesthesiol. 2009;19(1)
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thesia concerns for children with tuberous sclerosis.
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27. Ichikawa J, Nishiyama K, Ozaki K, Ikeda M, Takii Y,
Ozaki M. Anesthetic management of a pediatric patient
on a ketogenic diet. J Anesth. 2006;20(2):135-137.
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sleep apnea is common in medically refractory epilepsy
patients. Neurology. 2000;55(7):1002-1007.
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Rachael Kubiski, MS, RN-BC, CNRN, is a
clinical educator, Childrens Healthcare of At-
lanta at Scottish Rite, Atlanta, GA. Ms Kubiski
has no declared affiliation that could be per-
ceived as posing a potential conflict of interest
in the publication of this article.
EXAMINATION
CONTINUING EDUCATION PROGRAM

2.2
Perioperative Care of the www.aorn.org/CE

Child With Epilepsy

PURPOSE/GOAL
To educate perioperative nurses about caring for children with epilepsy who are
undergoing surgery.

OBJECTIVES
1. Describe epilepsy.
2. Identify factors that may trigger seizures.
3. Identify adverse effects of medications used to treat epilepsy.
4. Explain treatment options for children with epilepsy.
5. Discuss nursing care of children with epilepsy who are undergoing surgery.
The Examination and Learner Evaluation are printed here for your conven-
ience. To receive continuing education credit, you must complete the Exami-
nation and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS 3. In spite of treatment with medications and surgery,

1. The process that causes abnormal firing of neurons ____________ of patients with epilepsy experience
because of chemical and electrical malfunctions is intractable seizures.
called a. 25% to 30% b. 30% to 35%
a. status epilepticus. c. 35% to 45% d. 45% to 50%
b. epilepsy.
c. epileptogenesis.
4. Seizures are categorized as
d. seizures.
1. chronic.
2. generalized.
2. Factors that do not cause epilepsy but may trigger 3. focal.
a seizure in someone who is susceptible include 4. unclassified.
1. brain tumors. a. 1 and 2 b. 3 and 4
2. alcohol. c. 2, 3, and 4 d. 1, 2, 3, and 4
3. lack of sleep.
4. stress.
5. hormonal changes. 5. Almost all antiepileptic medications have the po-
6. genetics. tential for serious cognitive, psychosocial, and
a. 1, 5, and 6 b. 2, 3, 4, and 5 even life-threatening adverse effects.
c. 1, 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6 a. true b. false

AORN, Inc, 2012 May 2012 Vol 95 No 5 AORN Journal 645

May 2012 Vol 95 No 5 CE EXAMINATION

6. Antiepileptic medications may have adverse hema- 2. low carbohydrate consumption from fruits and
tologic effects, such as vegetables.
1. causing leukopenia. 3. high protein consumption from a low biological
2. decreasing hemoglobin and hematocrit. source.
3. increasing red blood cell count. 4. fluid restriction.
4. causing thrombocytopenia. a. 1 and 3 b. 2 and 4
5. causing metabolic acidosis. c. 1, 2, and 4 d. 1, 2, 3, and 4
6. causing respiratory alkalosis.
a. 1, 3, and 5 b. 2, 4, and 6 9. Perioperative nurses caring for pediatric patients
c. 1, 2, 4, and 5 d. 1, 2, 3, 4, 5, and 6 should consider both the patients chronological
age and developmental age in determining how to
meet the needs of the child.
7. The surgical procedures most commonly used to
a. true b. false
treat epilepsy are
1. corpus callosotomy.
10. Perioperative nurses caring for pediatric patients
2. hemispherectomy.
with epilepsy should
3. temporal lobe resection.
1. allow the caregivers to stay with the child as
4. ventriculoperitoneal shunt.
long as possible.
a. 1 and 3 b. 2 and 4
2. be sensitive to the fears of both the child and
c. 1, 2, and 3 d. 1, 2, 3, and 4
caregiver.
3. include the caregivers in the care of their child.
8. The ketogenic diet includes 4. refrain from judgment if the child is acting out.
1. high fat consumption from oils, butter, cream, a. 1 and 3 b. 2 and 4
and mayonnaise. c. 1, 2, and 4 d. 1, 2, 3, and 4

646 AORN Journal

LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM

2.2
Perioperative Care of the www.aorn.org/CE

Child With Epilepsy

T
his evaluation is used to determine the extent to
which this continuing education program met
your learning needs. Rate the items as described
below.
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Describe epilepsy.
Low 1. 2. 3. 4. 5. High
2. Identify factors that may trigger seizures.
Low 1. 2. 3. 4. 5. High
3. Identify adverse effects of medications used to
treat epilepsy. Low 1. 2. 3. 4. 5. High
4. Explain treatment options for children with
epilepsy. Low 1. 2. 3. 4. 5. High
5. Discuss nursing care of children with epilepsy
who are undergoing surgery.
Low 1. 2. 3. 4. 5. High
CONTENT
6. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
7. To what extent were your individual objectives
met? Low 1. 2. 3. 4. 5. High
8. Will you be able to use the information from this
article in your work setting? 1. Yes 2. No
9. Will you change your practice as a result of
reading this article? (If yes, answer question
#9A. If no, answer question #9B.)
9A. How will you change your practice? (Select all
that apply)
1. I will provide education to my team regard-
ing why change is needed.
2. I will work with management to change/
implement a policy and procedure.
3. I will plan an informational meeting with
physicians to seek their input and acceptance
of the need for change.
4. I will implement change and evaluate the
effect of the change at regular intervals until
the change is incorporated as best practice.
5. Other:
9B. If you will not change your practice as a result
of reading this article, why? (Select all that
apply)
1. The content of the article is not relevant to
my practice.
2. I do not have enough time to teach others
about the purpose of the needed change.
3. I do not have management support to make
a change.
4. Other:
10. Our accrediting body requires that we verify
the time you needed to complete the 2.2 con-
tinuing education contact hour (132-minute)
program:

AORN, Inc, 2012 May 2012 Vol 95 No 5 AORN Journal 647