CONTINUING EDUCATION

Special Needs Populations:
Perioperative Care of the
Child With Epilepsy
RACHAEL KUBISKI, MS, RN-BC, CNRN 2.2
www.aorn.org/CE

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indicates that continuing education contact hours are This program meets criteria for CNOR and CRNFA recertifi-
available for this activity. Earn the contact hours by reading cation, as well as other continuing education requirements.
this article, reviewing the purpose/goal and objectives, and AORN is provider-approved by the California Board of
completing the online Examination and Learner Evaluation at Registered Nursing, Provider Number CEP 13019. Check
http://www.aorn.org/CE. A score of 70% correct on the ex- with your state board of nursing for acceptance of this activ-
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pletes this program can immediately print a certificate of Conflict of Interest Disclosures
completion. Ms Kubiski has no declared affiliation that could be per-
Event: #12515 ceived as posing a potential conflict of interest in the publi-
Session: #0001 cation of this article.
Fee: Members $11, Nonmembers $22 The behavioral objectives for this program were created
The contact hours for this article expire May 31, 2015. by Rebecca Holm, MSN, RN, CNOR, clinical editor, with
consultation from Susan Bakewell, MS, RN-BC, director,
Purpose/Goal
Perioperative Education. Ms Holm and Ms Bakewell have
To educate perioperative nurses about caring for children
no declared affiliations that could be perceived as posing
with epilepsy who are undergoing surgery.
potential conflicts of interest in the publication of this
Objectives article.
1. Describe epilepsy.
2. Identify factors that may trigger seizures. Sponsorship or Commercial Support
3. Identify adverse effects of medications used to treat epilepsy. No sponsorship or commercial support was received for this
4. Explain treatment options for children with epilepsy. article.
5. Discuss nursing care of children with epilepsy who are
undergoing surgery. Disclaimer
AORN recognizes these activities as continuing education
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doi: 10.1016/j.aorn.2012.02.006
© AORN, Inc, 2012 May 2012 Vol 95 No 5 ● AORN Journal 635

which results in a seizure.4 chronic conditions. glected the effects of genetics on epilepsy. infections. prenatal injury.000 new 70% of all epilepsy diagnoses have no identifi- cases are reported each year. and environment.1 The rated by Lennox around 1960. genetics. hormonal children and older adults. head injury. and stress may trigger a seizure in most common neurological diagnosis. RN-BC. the potential for long-term neuro. CLASSIFICATION OF SEIZURES tions with various anesthetic agents. the Centers for Disease Con. Lennox and human costs. treat.3 The ness.2 RACHAEL KUBISKI. MS.2 Using data from the Bureau For many years.SPECIAL NEEDS POPULATIONS Perioperative Care of the Child With Epilepsy 2.5 cause of employers’ fears and misinformation The National Institute of Neurological Disor- about epilepsy.3 considerations for perioperative patients with epi- lepsy are addressed. 140.3 ders and Stroke and other federal agencies are In children. involved in several areas of research to identify logical. CNRN www. epilepsy someone who is susceptible.3 The significantly affect the quality of their lives. including potential interac. believed that the threshold for seizures was influ- comorbid disorders such as cerebral palsy and enced by complex interactions between genes and autism. in the United States. Intractable seizures are experienced by approxi- mately 25% to 30% of patients with epilepsy de- POTENTIAL CAUSES OF EPILEPSY spite medications and surgery. interest in the role of genetics was reinvigo- indirect cost of epilepsy is $15. affects approximately two million people poisoning. In addition. 2012 . brain tumors.4 Alcohol.5 billion. increased incidence of depression.4 Status epilepticus. a chronic condition in which sei. the scientific community ne- of Labor Statistics. Inc.1 Despite being the third changes. including reproductive issues.org/CE E pilepsy. approximately 50% to for Disease Control and Prevention. and cure epilepsy. cluster of seizures without recovery of conscious- cal malfunctions. and cognitive problems may how to prevent. how- trol and Prevention estimates that the direct and ever. however.3 The Epilepsy Phenome/Genome Project is just one of purpose of this article is to provide the reader the projects supported by the National Institute of with a brief overview of epilepsy and currently Neurological Disorders and Stroke to discover a available treatment modalities. special connection between genes and epilepsy. lack of sleep. behavioral.5 His emphasis was cost of epilepsy is also high in terms of disability on the multifactorial nature of epilepsy. mainly affecting able cause.aorn. Stroke states that although there are many zures occur. epilepsy continues to be elusive.5 The role of genetics in idiopathic discrimination against people with epilepsy be. Epileptogenesis is a process that causes abnormal a seizure lasting longer than five minutes or a firing of neurons because of chemical and electri. is a neurological disease that causes of epilepsy (eg. these remains one of the least understood of major factors do not cause epilepsy. and sudden unexplained death in epilepsy National Institute of Neurological Disorders and (SUDEP) are two life-threatening conditions for 636 AORN Journal ● May 2012 Vol 95 No 5 © AORN.1 According to the Centers Alzheimer disease).

convulsive or nonconvul- kopenia. and even life-threatening nosis. these include such items as type of sei. age best for the patient and which medication will of onset. Treatment of patients who have a history of ogy and prognosis. with or without impairment in logic effects.  severity of seizures. providing optimal seizure control. etiology. Although Against Epilepsy. a syn. Ultimately. older antiepileptic medication. many medications are available. adverse effects. Many of The three main categories of seizures are: these patients are on multiple antiepileptic med- ications. and TREATMENT OF EPILEPSY There are many treatment options available for red blood cell count. tic medication is used needs to be carefully sidered to be the best tool for pediatric epilepsy considered. severity. acidosis if they are on the ketogenic diet or are verse effects. may cause leu-  generalized (ie. nitive. signs and symptoms customarily occurring to- gether. Treatment options include potential to cause thrombocytopenia. precipitating factors. levetirac- etam may decrease hemoglobin. In addition. Pediatric patients taking The goal of medication therapy is to provide zonisamide are at increased risk for metabolic optimal seizure control while eliminating ad. . Newer antiepileptic medications that sive). anatomy. older antiepileptic medications valproic acid and carbamazepine. many patients will poorly controlled seizures.7 The earliest attempts at clas. A diagnosis of epilepsy requires that  ease of dosing. controlling having surgery. almost all have the potential for serious cog- and epilepsy of infancy and the resultant prog.12 Monotherapy (ie. tiracetam. however. taking into account and epilepsy syndromes. surgery. . an consciousness). and patients who erable adverse effects to the first antiepileptic have a long-term diagnosis of chronic epilepsy. and 11 also may cause leukopenia are gabapentin. both old and sification failed to distinguish the age at onset new. Valproate acid also in- Medications creases bleeding time. Felbamate also has the patients with epilepsy. and  underlying medical conditions and an epileptic disorder characterized by a cluster of comorbidities.9 Ep.14 AORN Journal 637 .10(p389) seizures must be carefully managed.6 medication attempted. not respond favorably or will experience intol- tiple antiepileptic medications. and felbamate.org which the patient with epilepsy is at special risk.8 A single seizure does not mean that a patient  individual circumstances. voked seizures without an identifiable cause. as do the antiepileptic medications.6 seizure activity with one antiepileptic medica- The risk of SUDEP is increased in patients with tion) is preferred. and sometimes prognosis . For example.  seizure type. leve-  unclassified epileptic seizures (Table 1). hematocrit. chronicity. the choice should be based on what is zure. as a result. ethosuximide. diurnal and circa. the patient has experienced two or more unpro.SPECIAL NEEDS POPULATIONS www. has epilepsy.aornjournal. those who require mul. are pre- with many revisions by the International League scribed several different medications. and diet.7 The 1989 classification by the Interna. ilepsy syndromes are defined as  interactions with other medications.13 drome does not necessarily have a common etiol. psychosocial.12 In addition. The choice of which antiepilep- tional League Against Epilepsy is widely con. many pa- The process of classifying seizures began in tients do not experience relief from seizures the 1960s and has been continually evolving with one medication and. have the greatest effect on quality of life while dian cycling. many of which have adverse hemato-  focal (ie.

tingling. twitching. Kotagal P.  May be misinterpreted as daydreaming. Pediatric Epilepsy Diagnosis and Therapy.May 2012 Vol 95 No 5 KUBISKI TABLE 1. numbness). the form of which is dependent on the area of seizure focus. Pediatric Epilepsy Diagnosis and Therapy. NY: Demos Medical Publishing. to as partial or local)  Origin of localization is either anatomic or functional. 2008:377-385. typically lasting less than 10 seconds.  Origin of localization is either anatomic or functional.  Clinical presentation is dependent on the area of the brain that is involved (eg. 1.  Patients frequently experience automatisms (eg. Pearl PL. feeling of déjà vu.  somatosensory or special (eg. complex partial seizures.  Consciousness is impaired or lost. Generalized (convulsive or  Typical absence nonconvulsive)  Involves both hemispheres.  Atypical absence  Involves both hemispheres. Childhood absence seizures.  Involves entire body. Classifications of epilepsies in childhood.  Patients may experience multiple seizures per day. 2008:137-146. 3. eye blinking.  Consciousness is impaired or lost.  Onset occurs before age five years and is often associated with mental retardation. atonic seizure  Involves both hemispheres. Dodson WE. Bourgeois BF. illusions). 2.  Complex focal: consciousness is impaired.  Motor involvement is bilateral. 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).  Duration is usually longer than typical absence. 3rd ed.  Consciousness is impaired or lost.  Patients frequently experience an aura. Localization-related epilepsies: simple partial seizures.  Any seizure has the potential to generalize.  An electroencephalogram is necessary for correct diagnosis.  autonomic (eg.  Eye blinking and other automatisms are more common. In: Pellock JM. 2008:323-334. jerking). and Rasmussen syndrome.  Significant likelihood of tonic or myoclonic activity or decreased postural tone. NY: Demos Medical Publishing. eds. flushing. and  psychic (eg. In: Pellock JM. Holmes GL.  Patients are briefly unaware of their surroundings and have no memory of the event. myoclonic. NY: Demos Medical Publishing. New York. Dodson WE. Bourgeois BF. 638 AORN Journal .  Tonic-clonic. Dodson WE.  Symptoms include  motor (eg. tonic.  Brief onset and recovery.  Focal with secondary generalization  Focal onset that spreads to other areas of the brain. clonic. Categories of Seizures1-3 Focal (formally referred  Focal: consciousness is not impaired. eds. occipital lobe onset will cause visual disturbances). eds. Nordli DR. Bourgeois BF. Pediatric Epilepsy Diagnosis and Therapy. lip smacking).  Patients may experience post-ictal confusion. New York. 3rd ed.  Onset and recovery are not as abrupt as in typical absence. 3rd ed. In: Pellock JM. New York. pupillary dilation).

and mood. also may still have a significant reduction in the sever- have the advantage of improved psychological ity and number of seizures. Many children with stimulator have the added benefit of improved epilepsy also have cognitive.19 stimulation (VNS) is an option.SPECIAL NEEDS POPULATIONS www. Many ministration in 1997. The diet includes high fat. have the poten- intractable seizures that do not respond to medica- tial to completely eliminate seizures in certain tions and for patients who are not surgical candi- patient populations. which diet can be curative in many patients.16 Since VNS Children with epilepsy undergo surgery for a vari- was first approved by the US Food and Drug Ad. Some types of epilepsy sur. meats.000 patients of these patients take multiple medications be- have undergone this procedure. al- vide significant reduction in seizure activity. safety in the with VNS.17 10 patients with focal cortical mayonnaise. low protein. and abdominopelvic regions. ety of reasons not related to their epilepsy. In patients for whom surgical includes fruits and vegetables. including hemispherectomy. soy).aornjournal.15 The exact Generally. and responsiveness. butter. low carbohy- has been in patients with partial epilepsy that drates. the surgery should be ponent is from high biological sources (eg. fish. The remaining 10% of the diet is dysplasia were seizure free on four-year follow- from carbohydrates and protein combined and up after surgery. poul- performed emergently to prevent further neuronal try. preoperative. and postoperative quency. performed in an outpatient setting. and AORN Journal 639 . alertness. Another important function and quality of life.18 Typically.19 The ketogenic undergo successful surgery for epilepsy. vagal nerve awareness.19 The pur- Corpus callosotomy is considered a palliative pose of this diet is to keep the patient in a state surgery and is not curative. Typically. VNS is used in patients with partial seizures.9 As for all patients. Surgical resection for intractable seizures can pro. Patients either eliminates seizure activity altogether or sig- who do not experience elimination of seizures nificantly reduces the number of seizures. which is important damage.org Surgical Options independence. corpus callosotomy. which means that 90% of the In a study involving 15 children performed by diet consists of fat from oils. psychosocial. The is caused by a lesion in the temporal lobe. intraoperative.15 benefit is discontinuation of or reduction in anti- For patients with intractable epilepsy who are epileptic medications.15 though its use is increasing for patients with gen- The surgical procedures most commonly used are eralized seizures. which typically is cause of the intractable nature of their epilepsy. This re- atonic seizures who are at high risk for injury sponse causes the body to use free fatty acids related to their seizure activity. temporal lobe resection. The protein com- resection is appropriate.18 Patients who rather than glucose for energy. Ketogenic Diet The ketogenic diet is another treatment option for gery. and Hudgins et al. UNRELATED SURGERY rax. but several studies have shown as much of surgery and resume them as soon as possible as a 50% reduction in seizure activity over time after surgery. which produces the meta- losotomy is reserved for patients with tonic and bolic response associated with fasting.16 typical ratio is 4:1. children with an implanted vagal nerve periods must be a priority. and fluid restrictions. corpus cal- of therapeutic ketosis.18 In addition to reducing seizure fre.18 because protein is needed for growth. learning. The most significant success dates. cream. tho. The vagal nerve is named for the Latin term for wanderer because CHILDREN WITH EPILEPSY UNDERGOING the vagal nerve wanders throughout the head. dairy. and hemispherectomy. which leads to improved not candidates for surgical resection. it is recommended that patients con- way in which VNS provides seizure relief is not tinue their antiepileptic medications up to the time known. more than 15.

oral communication. diagnosis of epilepsy. entire perioperative period. convulsant properties. Denver. The unpredictable nature of special needs of the child. Using dolls is also helpful for illustrat- Preoperative Considerations ing care procedures such as ostomy and gastric Unlike a patient with a cardiac condition. 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. general anesthesia have pro-  AORN Video Library: Preparing Children for Surgery convulsant properties. or  Periop Modules: Medications and Solutions. 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. In: Perioperative be avoided in most patients Standards and Recommended Practices. perioperative team to be aware of the potential portance of play in creating a safe environment. and these children may re. CO: AORN. anxiety. For older children and adolescents.aorn both and may need to be . 2012:251-300. and NPO status For example.9  Periop Modules: Patient and Family Education. taking into consider- epilepsy is one of the significant challenges in ation that the child’s developmental age may be caring for a patient with a history of seizures. http://cine-med. 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. 2011). very different from his or her chronological age. 1991). produce epileptiform activity on electroencephalography 640 AORN Journal . because it has the potential to Web site access verified February 16. lack of sleep. allowing the child to listen to his or her own heart first. the nurse to vary his or her routine to meet the August 28.aspx.aorn.org/PeriopModules/. avoided if possible. MD.aorn. anesthetic agent that should  Recommended practices medication safety. Sev- http://www. 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. doll’s heart before listening to the child’s heart or quire additional preoperative preparation time. Intraoperative and Anesthetic monly coexisting conditions (Table 2). Stress. 2012.org/PeriopModules/.com/index. http://www. with a history of seizures Inc. Cheng.org/Clinical_Practice/Clinical_Answers/ eral medications used for Clinical_Answers.php?nav⫽aorn. anti- (Ciné-Med. induction or inhibition. Considerations Nurses caring for pediatric patients need to Treating the patient with epilepsy requires the understand growth and development and the im.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. effects of anesthetic medications and their interac- Incorporating play into the care of a child can be tion with seizure medications. based on compre- hensive assessment data that address all com. http://www Sevoflurane is a newer . 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.

including antiepileptic medication levels.  all laboratory values (eg. if the child is on a ketogenic diet. dose. diazepam IV.  all seizure medications.  Establish IV access if this was not possible preoperatively.  Provide a safe and calm environment. if applicable.  Communicate any history of apnea or loud snoring. psychosocial.  Enforce practice guidelines governing infection control and prevention. oxygen. date.  Establish a therapeutic relationship with the child and caregiver. and time of the last dose of each medication.  Observe for adverse effects from anesthetics. recognizing the cognitive. if applicable. for hematologic conditions).  dietary restrictions (eg.  Communicate the use of vagal nerve stimulator or a ketogenic diet.  Ensure that the child took his or her antiepileptic medications before surgery.  the date of the last seizure. loud snoring.aornjournal. diazepam rectal gel). psychosocial. padded side rails).  Communicate a description of the child’s seizure activity and the date of the last seizure to the OR team.  Obtain baseline data regarding the child’s developmental age and impairment in cognitive.  Communicate antiepileptic medications and levels.  Perform a medication reconciliation and obtain the child’s history of allergies.  history of apnea.  Administer prophylactic antibiotics.  Establish IV access before arrival in the OR suite if possible.  a detailed description of the child’s seizure activity. or medication-induced hypoventilation.org TABLE 2. and behavioral implications of children with a history of epilepsy. obstructive sleep apnea. including rescue medications. including  the child’s age at seizure onset. lorazepam.  Ensure seizure precautions are available at the bedside (eg. Perioperative Nursing Implications: Children With Epilepsy Preoperative care  Schedule procedures for children early in the day to decrease fasting time.SPECIAL NEEDS POPULATIONS www. psychosocial. and the route. and behavioral skills.  Obtain baseline vital signs on the day of surgery. encouraging the child to communicate with staff members. depression).  Ensure maintenance of ketosis. frequency. and behavioral implications of children with a history of epilepsy. or analgesics.  the presence of a vagal nerve stimulator.  Ensure immediate access to rescue medications (eg. sedatives.  precipitating factors and known factors that lower the child’s seizure threshold.  Prepare the child’s family members for a longer-than-usual observation period after surgery. depending on the child’s psychosocial and behavioral impairment.  Maintain seizure precautions. bag/mask. obesity. do not use syrup-based oral medications or IV fluids containing carbohydrates). and providing comfort measures during invasive procedures. (continued) AORN Journal 641 . suction.  Encourage family members to participate by giving the child his or her medications.  Continuously monitor the child for seizure activity. recognizing the cognitive.  Use visual aids and play therapy when communicating with the child. Intraoperative care  Provide a safe and calm environment. including auras. and  the presence of comorbidities (eg.  Incorporate the child’s routine in the plan of care.  Obtain a relevant history.

acid-base balance is also modified by the keto- ports by Akeson and Didriksson21 described seizure genic diet.  Ensure immediate access to rescue medications if needed.  Ensure that the child resumes taking his or her antiepileptic medications as soon as possible after surgery. without a history of seizures as they are emerging The ketogenic diet is only effective if the patient from anesthesia. The use of sweetened syrups old in patients who have febrile convulsions.  Provide a favorite toy or other objects of comfort. sidered or avoided in any patient with a history of Monitoring the patient’s acid-base balance seizures.25 and Propofol may be a safer choice for anesthesia methohexital26 are other anesthetic agents that have than a high concentration of sevoflurane in inh- the potential to induce seizures in patients or lower alation induction because of the potential of 642 AORN Journal . during inhalation in both pediatric and adult patients the seizure threshold in patients with a history of who do not have a history of seizures. Sevoflurane may be a popular choice for the syrups will cause the ketone levels to drop pediatric patients because it has a pleasant odor and and the patient will no longer be in ketosis. also has been reported to be responsible for both There are special anesthesia considerations for focal and generalized seizures in patients with and surgical patients who are on the ketogenic diet. its use should be carefully con. is contraindicated in a patient on the ketogenic cranial pathology. because ketone bodies may cause metabolic aci- ric patient. selected if possible. recognizing the cognitive.16 ketamine. The induced seizures have been reported.  Make clinical judgments regarding pain control based on cues and information from the child’s family members.27 For family history of seizures after anesthesia using pediatric patients.23 Enflurane has also been shown to pro.  Communicate with the child who has sensory impairment to prevent feelings of isolation. however. and behavioral implications of children with a history of epilepsy. intra. throughout the perioperative period is necessary duce electroencephalographic changes in the pediat. medications and to disguise their unpleasant taste flurane has the potential to lower the seizure thresh.  Maintain IV access.24 Etomidate. which decreases the seizure threshold.  Monitor the child’s hematologic status.  Provide discharge instructions to the child’s family members based on the interdisciplinary plan of care.20 Other instances of sevoflurane. bohydrates is contraindicated for the same reason.16 Sevoflurane epilepsy and should also be avoided. remains in a state of therapeutic ketosis. psychosocial.  Update the family members on the child’s condition and allow family members to be with the child in the postanesthesia care unit as soon as this is safe and practical. given its proclivity use of IV fluids containing amino acids and car- to be proconvulsant. (continued) Perioperative Nursing Implications: Children With Epilepsy Postoperative care  Provide a safe and calm environment. with flavored syrup. Rewari and Sethi22 reported that sevo. and maintaining both ketosis and mod- activity in a healthy three-year-old child with no ified acid-base balance is vital for preventing history of seizures and a four-year-old child with a seizures during the perioperative period. it is common to use oral pre- sevoflurane.  Maintain the airway and monitor the child for signs of obstruction or respiratory depression. The low solubility in blood. Two case re.  Monitor the child continuously for seizure activity.May 2012 Vol 95 No 5 KUBISKI TABLE 2. and hyperventilation as well as diet because the carbohydrates and amino acids in epilepsy. and alternative medications should be dosis.

9. Allowing the caregivers to stay with the child poventilation. Shorvon S. What is the burden of epilepsy in the United States? the vagal nerve.24 They are also at increased risk Centers for Disease Control and Prevention. 2005. it is .org sevoflurane to illicit seizure activity.cdc.29 A child’s in- epileptic medications are metabolized through the ability to cope with the uncertainties of epilepsy liver. Neurology Asia. 6. Epilepsy Res. patients with a vagal nerve viating the stress of surgery.aornjournal. Patients research. About epilepsy. Engel J Jr. Seizures and epilepsy: hope through research.cfm.24 The occurrence of obstructive sleep tive to the fears of both the child and caregiver apnea may be related to chronic antiepileptic and refrain from judgment if the child is acting medication therapy and medication-induced hy- out. National Institute of Neurological Disorders and Stroke. and 10.15 The cognitive. and seizures that occur during care of the child will go a long way toward alle- sleep. National In- stitute of Neurological Disorders and Stroke. many challenges because many of these children 8. The parents and caregivers of chil- risk for symptoms of obstructive sleep apnea. http://www . Enright SM.cfm.gov/disorders/epilepsy/detail_epilepsy be mistaken as seizure activity. Pediatric seizure and epilepsy Caring for children with a history of epilepsy has classification: why is it important or is it important? Semin Pediatr Neurol.28 In addition. One of the most common comor. Gratnix AP.nih. as is propofol. Rekate HL.ninds. http:// ence dystonic movements.9 However. 2011.70(Suppl 1):S5-S10.24 cessed December 19.16(1):16-22. Ac- pressant effects of opioids. Not surprisingly. http:// unit nurse to be familiar with the type and de- www. have proximately one-third of this patient population higher levels of anxiety. Accessed December 19.gov/epilepsy/basics/faqs. 2006. 2011.24 stimulator may have depressed postoperative re- spiratory efforts and increased obstructive airway References complications as a result of chronic stimulation of 1. However.16(Suppl 1):5-8. and this should not www. CHILDREN WITH EPILEPSY 7. 2011.SPECIAL NEEDS POPULATIONS www. based on epidemiological studies. ap- dren with epilepsy often are overprotective.htm#4.29 Nurses should be sensi- morbidities. Accessed for severe postoperative apnea caused by the December 19. http:// www. which increases stress on the family lepsy. 4. combined effects of VNS and the respiratory de. bid conditions. Curing epilepsy: the promise of research. 2009. Heredity in epilepsy—an historical over- crucial that true seizure activity be recognized view.30(4):389-399. 2. Accessed December 19. 1989.27 Many anti. Epi- lepsy Foundation. and treated appropriately. It is important for the postanesthesia care 3.epilepsyfoundation. parents’ response to their patients on the ketogenic diet depend on optimal child’s epilepsy is closely correlated with the psy- liver function as their energy source. also have significant comorbidities and develop. which can increase the child’s psycho- patients on the ketogenic diet. http://www. AORN Journal 643 .gov/disorders/epilepsy/epilepsy_ scription of seizures the patient has. obesity as an adverse effect of as long as possible and including caregivers in the medication. Epilepsy Foundation. and are reluctant to dis- has obstructive sleep apnea along with other co- cipline their children. is depression. chosocial care needs of the child.27 social dysfunction. so maintenance of general is often influenced by maladaptive behaviors in anesthesia with sevoflurane may be preferred in the family. 5. 2011. 2011.htm#187173109. mental delays.nih.5(4):118-121.ninds. SUDEP (sudden unexpected death in epilepsy). 2011. Epilepsy in anaesthesia and intensive care. Accessed CHALLENGES OF CARING FOR December 19.htm. often shiver after general anesthesia or experi.org/ aboutepilepsy/healthrisks/sudep/index. Troester M. unit. Commission on Classification and behavioral problems these children exhibit are Terminology of the International League Against Epi- considerable. ILAE classification of epilepsy syndromes. psychosocial.30 The unpredictability of seizures further complicates the treatment of pa- Postoperative Considerations tients with a history of epilepsy who are undergo- Patients with refractory seizures are at increased ing surgery. Proposal for revised classification of epilepsies and epi- leptic syndromes. Contin Educ Anaesth Crit Care Pain. Epilepsia.epilepsyfoundation.org/aboutepilepsy/index.

Youth with 2005.May 2012 Vol 95 No 5 KUBISKI 11. Pediatric der’s Care of the Patient in Surgery. Takii Y. Therapeutics in pediatric epi. ing psychosocial care needs in children with new-onset 17. Mayo Clin Proc. Fahy BG. Anesthesia. Austin JK.19(1) 13. 2011:111-143. Buelow JM. Atlanta. Classifications of epilepsies in childhood. Malow BA. Khandrani J. therapy to monotherapy AED conversions. tudes toward their condition. 27. 19.41(2):70-76. Zonegran (zonisamide) package insert. Sidani S. CNRN. Mayo Clin Proc. nerve stimulation: overview and implications for anes- Transitional polytherapy: tricks of the trade for mono. Vagal nerve stimulation: 29. Children’s Healthcare of At- 21. Jarrar RG. Curr Neuro. AANA J.29(1):20-25. RN-BC. Perkins SM. 2009. New York. Epilepsy Diagnosis and Therapy. MO: Mosby Elsevier. 14th ed. Roy R.78(3):359-370. 2004. 2011. Efficacy of dietary treatments for epilepsy. genic diet.23(2):113-119.20(2):135-137. 16. Continu- a case report. Dahake S. 2007. Hatton KW. Palasis S. 2003. Bourgeois BF. Rajput A. Part 1: The new antiepileptic drugs and the keto. Bowes R. 23. Anaesth Intensive Care. epilepsy: development of a model of children’s atti- 18. McLarney JT. Ichikawa J. GA. Ozaki K. Woodcliff Lake.20(2) clinical educator. Dunn DW. Burns TG. Shore CP. AANA J. Vagal 12. 2009. Levy K. Johnson CS. thesia concerns for children with tuberous sclerosis. 2006. 2008:137-146. Thompson ES. Maturen K. J Hum Nutr Diet. ed. Internet J Anesthesiol. Rewari V. Willemsen-Dunlap A. Nishiyama K. Austin JK. Jarrar RG. 2010. induced seizures. Ketamine pharmacol. Buchhalter JR. Bramley T. Wennberg RA. J Anesth. flurane. Neal EG. St Louis EK. Rothrock JC. Ozaki M.48(4):405-407. 2007. 644 AORN Journal .55(7):1002-1007. Pittman T. Internet J Anesthesiol. J Neurosci Nurs.78(2):146-150. Sethi D. Buchhalter JR. Acta has no declared affiliation that could be per- Anaesthesiol Scand. Henry TR. Quality of life in epilepsy. 25. Dix D. Pediatr Neurosurg. Cheng R. In: DeLamar LM. Ms Kubiski induction with sevoflurane in young children. Didriksson I. Garnett WR. 24. 26. lation. Convulsions on anaesthetic lanta at Scottish Rite. Cross JH. 14. St Louis. Flamini JR. 2006. Poochikian-Sarkissian S. is a 20.74(3):219-225. Devins GM. Nordli DR.35(5):788-791. Verma N. Obstructive Nurs. 2006. 35(2):123-140. 2000. 2009. 2003. Anesthetic management of a pediatric patient 15. lepsy. on a ketogenic diet. 22. Recurrence of focal seizure activity ceived as posing a potential conflict of interest in an infant during induction of anaesthesia with sevo. Septer S. Therapeutics in pediatric epi. MS. Anesth Analg. Repetitive focal seizures after sevoflurane anes- thesia. in the publication of this article. Gold ME. Ikeda M. Can J Neurosci 28. Surgical treatment of epilepsy in children 244-250. Higgins D. Child Health Care.7(2):83-95.103(5):1241-1249.41(5): Gilreath CL. 3rd ed. NY: Demos Medical Publishing. thesiologists. 2006. NJ: Eisai Inc. Alexan- In: Pellock JM. Hudgins RJ. Rachael Kubiski. Neurology. epilepsy and their parents. 2009. 2010. Akeson J.78(3):371-378. Part 2: Epilepsy surgery and vagus nerve stimu. Shen J. sleep apnea is common in medically refractory epilepsy patients. 30. Dodson WE. Anes- lepsy. caused by focal cortical dysplasia.

epileptogenesis. epilepsy. 2. c. 4. 3. and 6 a. 3. To receive continuing education credit. Inc.EXAMINATION CONTINUING EDUCATION PROGRAM 2. 2. genetics.org/CE. Describe epilepsy. 25% to 30% b. and 6 d. 4. c. brain tumors. 30% to 35% a. 2012 May 2012 Vol 95 No 5 ● AORN Journal 645 . The Examination and Learner Evaluation are printed here for your conven- ience. 4. generalized. Seizures are categorized as d. 1. 4. 1. 2.aorn. focal. 5. 1. 1. false © AORN. you must complete the Exami- nation and Learner Evaluation online at http://www. tential for serious cognitive. Identify adverse effects of medications used to treat epilepsy. 5. and 4 d. 45% to 50% b. psychosocial. Factors that do not cause epilepsy but may trigger 3.org/CE Child With Epilepsy PURPOSE/GOAL To educate perioperative nurses about caring for children with epilepsy who are undergoing surgery. 2. The process that causes abnormal firing of neurons ____________ of patients with epilepsy experience because of chemical and electrical malfunctions is intractable seizures. true b. status epilepticus. and a. 2. Identify factors that may trigger seizures. 3. 3. 3. 5. unclassified. 2. and 6 b. c. chronic. 1 and 2 b.2 Perioperative Care of the www. OBJECTIVES 1. QUESTIONS 3. seizures. Explain treatment options for children with epilepsy. stress. and 5 even life-threatening adverse effects. 2. called a. 3 and 4 2. 1. Almost all antiepileptic medications have the po- 6. and 4 3. a seizure in someone who is susceptible include 4. Discuss nursing care of children with epilepsy who are undergoing surgery. In spite of treatment with medications and surgery. 5. 3. lack of sleep. hormonal changes. a. 5.aorn. 5. c. 2. alcohol. 1. 4. 1. 35% to 45% d.

3. high protein consumption from a low biological 2. 1. c. hemispherectomy. 7. 2 and 4 and mayonnaise. 1. 1. 2 and 4 2. a. 1. 1. c. 1. 1. 2. 2. refrain from judgment if the child is acting out. 3. temporal lobe resection. a. and 4 646 AORN Journal . 4. and 5 d. Perioperative nurses caring for pediatric patients 2. 2.May 2012 Vol 95 No 5 CE EXAMINATION 6. high fat consumption from oils. 1. cream. a. allow the caregivers to stay with the child as 4. 1. causing thrombocytopenia. fluid restriction. 1. 10. 3. 2 and 4 5. 4. long as possible. and 5 b. 2. 3. 1 and 3 b. 3. 1 and 3 b. 3. 2. 2. with epilepsy should 3. 1 and 3 b. 4. decreasing hemoglobin and hematocrit. butter. and 3 d. 2. false treat epilepsy are 1. a. The surgical procedures most commonly used to a. source. 2. Antiepileptic medications may have adverse hema. and 4 caregiver. and 4 d. 3. 4. and 4 6. 3. 1. include the caregivers in the care of their child. 1. be sensitive to the fears of both the child and c. 4. and 6 should consider both the patient’s chronological age and developmental age in determining how to meet the needs of the child. corpus callosotomy. increasing red blood cell count. and 4 d. low carbohydrate consumption from fruits and tologic effects. causing leukopenia. The ketogenic diet includes 4. and 6 9. 2. such as vegetables. 2. 5. 8. Perioperative nurses caring for pediatric patients c. ventriculoperitoneal shunt. causing respiratory alkalosis. causing metabolic acidosis. true b.

High 4.org/CE Child With Epilepsy T his evaluation is used to determine the extent to 9. 4.) below. High 4. To what extent were the following objectives of this 2. Rate the items as described #9A. 3. To what extent were your individual objectives 10. Explain treatment options for children with 5. Inc. High the time you needed to complete the 2. 4. 1. 3. apply) Low 1. 4. 2. 9A. 3. High physicians to seek their input and acceptance 2. Yes 2. 4. 4. 3. of the need for change. 3. 3. Low 1. High the change is incorporated as best practice. Other: epilepsy. 2. Low 1. 2012 May 2012 Vol 95 No 5 ● AORN Journal 647 . If you will not change your practice as a result 5. Other: 7. 4. 5. 2. 5. why? (Select all that who are undergoing surgery. Will you change your practice as a result of which this continuing education program met reading this article? (If yes. 2. I do not have management support to make knowledge of the subject matter? a change. Identify factors that may trigger seizures.2 Perioperative Care of the www. Will you be able to use the information from this tinuing education contact hour (132-minute) article in your work setting? 1. I will provide education to my team regard- OBJECTIVES ing why change is needed.aorn. I will work with management to change/ continuing education program achieved? implement a policy and procedure. No program: © AORN. 2. answer question #9B. 4. I will plan an informational meeting with Low 1. Identify adverse effects of medications used to effect of the change at regular intervals until treat epilepsy. The content of the article is not relevant to my practice. answer question your learning needs. Low 1.LEARNER EVALUATION CONTINUING EDUCATION PROGRAM 2. Our accrediting body requires that we verify met? Low 1. 2. 6. 3. 5. Discuss nursing care of children with epilepsy of reading this article. Low 1. 5. I will implement change and evaluate the 3. To what extent did this article increase your 3. 5. If no. 3. 2.2 con- 8. 5. 5. 4. I do not have enough time to teach others CONTENT about the purpose of the needed change. 2. How will you change your practice? (Select all that apply) 1. High 1. Describe epilepsy. High 9B.