Preoperative Seizure Control and Perioperative Anesthetic Outcomes in Children Receiving Levetiracetam Versus Phenytoin: A Hospital-Based, Prospective, Comparative Cohort Study

Background and objective Epilepsy is a common neurological disorder in children, and the perioperative period is associated with an increased risk of seizures and anesthetic complications. Intravenous phenytoin loading is associated with hemodynamic instability, whereas chronic oral therapy has minimal intraoperative cardiovascular effects. In contrast, levetiracetam has more favorable pharmacokinetics and fewer drug interactions. However, evidence comparing perioperative outcomes between levetiracetam and phenytoin in elective pediatric surgical settings remains limited. This study aimed to compare perioperative seizure incidence and anesthetic outcomes between children receiving levetiracetam and phenytoin and to identify predictors of postoperative seizures. Methods This hospital-based, prospective, comparative cohort study was conducted over 18 months at a tertiary care center. Two hundred children aged 1-18 years with epilepsy undergoing elective non-neurosurgical procedures under general anesthesia were enrolled, with 100 receiving levetiracetam and 100 receiving phenytoin monotherapy. Antiepileptic therapy was continued perioperatively. The primary outcome was the occurrence of postoperative seizures within 24 hours. Secondary outcomes included preoperative seizure-free status, intraoperative and postoperative complications, delayed emergence, recovery time, and length of hospital stay. Data were analyzed using appropriate statistical tests and multivariable logistic regression analysis to adjust for confounders. Results Baseline characteristics were comparable, except for a higher proportion of patients who were seizure-free preoperatively in the levetiracetam group (79% vs. 54%, p < 0.001). Postoperative seizures occurred in 6% of the levetiracetam group and 12% of the phenytoin group (p = 0.138). Delayed emergence was significantly lower with levetiracetam (7% vs. 19%, p = 0.012). Recovery time (34.5 ± 9.1 vs. 51.4 ± 12.8 minutes) and hospital stay (2.95 ± 0.86 vs. 4.83 ± 1.39 days) were significantly shorter in the levetiracetam group. After adjustment, preoperative seizure-free status showed a protective trend, whereas the type of antiepileptic drug (AED) was not independently associated with postoperative seizures. Conclusions Levetiracetam and phenytoin demonstrated comparable postoperative seizure incidence after adjustment for confounding factors. However, levetiracetam was associated with improved perioperative recovery, including reduced delayed emergence and a shorter hospital stay. These findings suggest that while the efficacy of seizure prevention may be similar, differences in pharmacological profiles may influence perioperative safety and recovery outcomes in pediatric surgical patients.