PAEDIATRIC ALTERED CONSCIOUS LEVEL GUIDELINE
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DELPHI PROCESS

Round one

3. Capillary glucose

Statement 3a

Children with altered conscious level should have a capillary glucose checked within 15 minutes of presentation

% Agree	% Disagree	Result
91.4%	5.7 %	Included

Position	Comments
Neuro	Commentsmost probably sooner
Paed	Prefereably within 5 minutes ( bedside testing)
Paed	The capillary glucose should be checked ASAP
Neuro	Need true blood glucose too
Metab	Should be immediate
Neuro	Or earlier
Metab	Sooner if poss – ie asap/now
Biochem	A stix test result must be confirmed by a laboratory quantitative result
Paed	might be difficult but should try to achieve
PICU	once ABCD initially assessed – should be within 5 mins if above ok

Statement 3b

(i) In a child 3 months of age or over with reduced conscious level, a capillary glucose level of less than 3.5 mmol/l is low and should be investigated further and corrected

% Agree	% Disagree	Result
58.3%	16.7 %	Discussed in Round 2

Position	Comments
Paed	But should definitely be checked with lab as well as bedside measurement. Out local policay uses cut off of 2.6 mmol/l irrespective of age
Neuro	Some might say 3.3
ED P	Probably need to be aware of it and repeat sooner rather than later, but may initially only treat those with blood sugar under 3 mmol/l
Renal	I would take a definition of hypoglycaemia as <=2.7 for all ages
Metab	The crucial question here is how hs the glucose been measured. If it is a laboratory glucose the answer is no but if it is a BMstix then it is questionable because they are not accurate in the low range
Metab	Cutoff probably too high
Neuro	I think there’s sufficient data to indicate that capillary sticks are not reliable/sufficiently accurate at hypoglycaemic levels and this statement needs to refer to true blood glucose. If low/very low investigation/correction can be initiated but must be confirmed by true blood glucose
PICU	See the work of Koh, Aynsley-Green et al – definitions vary in the textbooks
Neuro	Neurophysiological evidence would suggest a level of 2.8 mmol/l
ED	Ought to be checked first
PICU N	However, not likely to be cause of reduced consciousness
Biochem	3-3,5 is borderline – glucose needs to be re-checked – also must be a quantitative lab. glucose
PICU	confirm with lab value, urine Ix minimum

(ii) In a child under 3 months of age with reduced conscious level, a capillary glucose level of less than 2.6 mmol/l is low and should be investigated further and corrected.

% Agree	% Disagree	Result
94.3%	2.9 %	Included

Position	Comments
Neuro	Some might say 2.5
Neuro	This is all pretty controversial: 2.6mM is a minimum. Some would argue for a higher figure (i.e. same as older children). Is it sensible to be trying to cover neonates in this guideline?
PICU	See the work of Koh, Aynsley-Green et al – definitions vary in the textbooks
PICU N	However, not likely to be cause of reduced consciousness

Statement 3c

In a child with reduced conscious level, a capillary glucose level of 11.0 mmol/l or greater is high and should be investigated further. (The investigations and treatments of hyperglycaemia will be addressed later)

% Agree	% Disagree	Result
66.7%	6.1 %	Discussed in Round 2

Position	Comments
Paed	Need to interpret in context of history – often stress response. Ensure repeat estmation one to two hours later
ED P	Need to be aware, but may be stress response and treatment guided by other findings
Neuro	Comments not necessarily- could be stress related/seizure
ED P	Not necessarily an indication for further investigation. Could be elevated as part of stress response and settle spontaneously
ED	I would manage as part of a series of BS levels and in the clinical context
Paed	Not so sure. Can get increased blood glucose in meningitis / sepsis without requiring further Ix (esp. in young children)
PICU	may just require interpretation with clinical story