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[IP] Crystallized Insulin in Cannula?? (Long)

Hello All:

I have a situation that I need for feedback for.  Jake's BS numbers were high
last night before bed, probably due to the ice cream he ate after dinner and
forgot to bolus for.  So he bolused and went to bed.  This was the first night
in months that I didn't get up and check him.  He woke up at 400, so I knew
that he had probably been high all night.  His site wasn't due to be changed
out until tonight, so I didn't think there was a site problem.  I primed and
it looked fine.  Then decided to call MM to get more suggestions.  She had me
prime again to verify that the problem was the site and not the pump.  So we
changed the site.

When I looked at the cannula that we removed from the site, it was not kinked,
but I could see what looked like crystallized insulin in the 3mm cannula, from
the tip to about halfway down.  This is what was causing the blockage and was
the reason Jake's numbers were high.

Has anybody ever seem this?  Why did this happen?  Anybody have any ideas?

Thanks in advance....
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