Type 1 diabetes: insulin therapy, technology and ambulatory care — structured clinical encounter

Structured encounter testing the ambulatory care of a seven-year-old on an insulin pump who presents with abdominal pain, vomiting and ketones, with a normal-looking cannula site: recognition of the pump-cannula pitfall, the immediate pen correction and site change, the sick-day education that reinforces never stopping insulin, the HbA1c and time-in-range targets, and the communication with a frightened family about a near-miss.

structured clinical encounter2 min readVerification in progress

Prompt

A seven-year-old girl with type 1 diabetes on an insulin pump for two years presents to the emergency department with six hours of abdominal pain and vomiting. She is alert but mildly dehydrated. Point-of-care glucose is 19 mmol/L and blood ketones are 2.8 mmol/L. Her cannula site looks normal and the pump reservoir is half full. You are the paediatric registrar assessing her, stabilising her, and teaching the family how to prevent a recurrence.

Clinical context

The child has type 1 diabetes controlled on a continuous subcutaneous insulin infusion pump. Her rapid onset of ketosis with a normal-looking cannula site and a half-full reservoir is the classic presentation of pump-site failure. Because a pump delivers only a rapid-acting analogue with no long-acting depot, a blocked or dislodged cannula removes all insulin within hours, and ketones climb far faster than in a child on injections. [2]

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References4Show ledger

[1]Phelan H; Hanas R; et al Sick day management in children and adolescents with diabetes. Pediatr Diabetes, 2022.PMID 36093857
[2]Biester T; Berget C; et al ISPAD Clinical Practice Consensus Guidelines 2024: Diabetes technologies — insulin delivery. Horm Res Paediatr, 2024.PMID 39657603
[3]Cengiz E; Danne T; et al ISPAD Clinical Practice Consensus Guidelines 2024: Insulin and adjunctive treatments in children and adolescents with diabetes. Horm Res Paediatr, 2024.PMID 39884261
[4]de Bock M; Agwu JC; et al ISPAD Clinical Practice Consensus Guidelines 2024: Glycemic targets. Horm Res Paediatr, 2024.PMID 39701064