Original German title: Himversagenbei einer schwangeren Patientin. Der Merkurstab 1994; 47: 445-51. English by A. R. Meuss, FIL, MTA. Medical staff caring for the patient: H. Gugg, J. Meyer, W. Kettnaker, anesthetists; R. Schweigert, T. McKeen, P. Bavastro, internists; A. Kuck, E. Reichelt, gynecologists. Abridged advance version of a paper to be published in Anthwposophische Medizin auf der Intensiustation. Historische Cesichtspunkte. ScMaf. Narkose. Himtod. Eine besondere Krankengeschichte Persephone series.

Preliminary remark

Treatment and care of a patient in cerebral failure are nothing unusual in an intensive care unit. Treatment calls for a cautious, sensitive approach to the patient's biographic situation. Understanding reincarnation and karma, we gain the inner approach that enables us to act. Decisions have to be made on short notice by individuals who must take the responsibility for them; democratic processes are out of place here.

Below, an evolution is described that happened at the Filderklinik in 1991. It was special not because of the patient's cerebral failure but because in spite of prolonged resuscitation her pregnancy proceeded; and as far as we could tell the fetus was developing normally and on term. The second factor was the confidence shown by the husband; his will gave us the strength to act and to help.

The patient's situation became known to us when she was still in another hospital. Early and major decisions had already been made. The severity of the condition and the normal pregnancy had been established; the husband's decision to do everything possible to give the child the chance to life determined the issue.

The couple had been married for a long time, with their wish for a child unfulfilled. Then the child had announced its coming. The pair deliberately had chosen not to have an amniocentesis or chromosome studies done.

Contact had first been made with the Filderklinik when the couple regis- tered for the coming birth. The husband consequently came to ask us if we would take on the further treatment of his sick, pregnant wife. A transfer from the first hospital had become necessary because treatment was obviously going to be difficult and required close collaboration between intensive care experts and gynecologists. The other hospital had no obstetric unit. The request was first of all made to our colleague, T. McKeen, since deceased. A relationship of trust was established with the husband in a number of talks. Medical and nursing staff, therapists and the chaplain at the hospital were prepared to enter into this situation with its special destiny aspects and do all they could to help in this threshold, borderland situation. The patient was therefore transferred to us, with Dr. McKeen initially responsible for coordination.

In a situation such as this, external aspects or argumentative discussions do not prove helpful. Aspects of the anthroposophic study of man gave individuals among us the inner certainty they needed and the criteria to form an independent opinion, both essential for responsible action. Action was thus justified, and indeed became imperative, on this basis, independent of the potential for evolution; it was not justified in retrospect, on the basis of a "positive" evolution.

When the patient came to us, we had familiarized ourselves with the condition of cerebral failure; similar situations were known to us from the literature.38^ We were not sure, however, of our ability to keep her general condition stable for such a long period (with reference to the child). In the same way, we were uncertain how well the child would develop. None of us considered the patient in our care to be dead. We felt committed to the developing life of the child, the path of incarnation on which it had set out, and to its will. The husband/father's inner conviction and confidence were a major factor - his profound sense of responsibility did much to determine our decision.

We had done nothing to keep the affair secret at the time. Friends of the hospital and some of the papers knew about the patient; but, significantly, the matter did not become public knowledge, nor was it exaggerated. The atmosphere of privacy and security helped and supported our efforts at treatment. We sought to create a calm, quiet atmosphere around the patient, to convey a feeling of protection and security to mother and child. Intensive care units are normally places of fairly restless activity, as much has to be done (diagnostic procedures, treatment, monitoring), and several patients have to be cared for. The more complex and threatening the patient's condition, the more frequent these interventions, for many functions that have failed or are abnormal must be consciously done from outside. The measures that had to be taken for our patient were extensive, as the integration of almost all vital functions was lacking.

From the point of view of the threefold human being, the patient was in an extraordinary situation. The system of physical sensory perception was not functioning because of the cerebral failure; the central nervous system was also not functioning; she was unconscious. The spinal cord system still showed some activity, resulting in strange automatic movements of the limbs that suggested astral activity no longer guided by the ego.

In the rhythmical sphere, spontaneous respiration had ceased and artificial respiration was necessary. Internal respiration, the exchange of gases, was still intact, however. The cardiovascular system was able to function but showed "meaningless" reaction patterns such as tachycardia-bradycardia and major fluctuations in blood pressure for which there were no obvious explanations.

Apart from the above-mentioned automatic movements, function had been lost in the limbs. Metabolism was sluggish, gastrointestinal motility reduced, with partial atony making tube feeds difficult. Nutritional require- ments had to be met in an unphysiological manner, mainly by means of infusions made directly into the circulatory system.

The outer body form remained remarkably intact throughout; unlike many other patients in cerebral failure she developed no appreciable edema of face and hands and no bedsores.

On the other hand, there were definite signs of excarnation: anemia, disorders of temperature and blood sugar regulation; drops in blood pressure; meaningful, purposeful reactions were non-existent; hormonal regulation (e.g. diabetes insipidus, adrenal insufficiency) and water metabolism (e.g. profuse sweating) were seriously disrupted. This brief phenomenological description shows that the ego organization's power of integration was severely disturbed.

Remarkably and extraordinarily, it proved possible to keep the situation relatively stable for such a long time by using the external methods of inten- sive care. The question inevitably arises as to the role the developing child played in maintaining the patient's will to live.

Fortunately years of observation in the intensive care unit enabled us to realize that rapid deterioration set in about ten days prior to the caesarean. Subtle changes occurred: signs of excarnation increased, help given from outside generally could no longer stabilize the situation. It was possible to intensify the necessary contacts with the neonatologists in good time.

Our task was to intervene from outside and try to regulate physical processes the patient was no longer able to maintain.

The husband and father played a central role in the whole process. He was at the bedside for long periods during the day, reading to his wife, talking to her and the child, playing her favorite music on tapes. Other media (radio, TV) were not available in the room.

It is not surprising that in such a difficult situation discord and misunderstandings would sometimes arise - for the husband and also for us. Would it be fair, however, to express an opinion, let alone make judgments, considering the stresses to which the husband was exposed? He found the strength and the courage to be there for his wife in his own way, and to make a contribution that was vital for the child.

Art therapy (music and speech) and eurythmy therapy were used inaddition to medical treatment throughout. Patients in cerebral failure cannot use their sense organs but can be addressed and perceived through eurythmy therapy at a non-sensory level, that of imponderable respiration.

What gave us the necessary certainty in our actions? With eurythmy and art therapy the point is not primarily if patients feel pleasure or not, sympathy or antipathy; what matters is recognition of the underlying objective laws. Eurythmy therapy conveys movements to the patient that follow the laws of the ether body as the bearer of health, enabling the patient to connect with these laws again. The situation is the same with music therapy and speech formation. The real question is which eurythmy exercises, which instrument, what music and what texts are indicated for the patient's particular situation. The answer may be found by study and the appropriate experience. During these therapy sessions the respirator, being rigid in its mode of operation, was often disconnected, with artificial respiration given by hand.

Careful observation showed, however, that the therapy also influenced the anesthetist giving the artificial respiration, who gave himself up to it. As a result the patient was at times not given adequate ventilation (evident from the decrease in oxygen saturation). It became clearly apparent how difficult it is to take over the patient's ego-integration functions from outside, in waking consciousness. Great wisdom prevails in these things when people are in normal health.

Clinical Course

The patient, aged 33, had never been seriously ill. A left inguinal hernia had been surgically treated at an earlier date. In 1989 she had a thyroidectomy, with part of the parathyroid removed, which resulted in hypocalcemia. She took dihydrotachysterol (DHT) originally, and then calcium. Prior to the operation she had indefinable cardiac arrhythmias. Her pregnancy was in the 17th week, with the date for the birth set at 15 December 1991.

On 4 July 1991 the patient collapsed for reasons unknown in a park in Stuttgart. A medical practitioner who happened to be passing started resuscitation; following the arrival of the emergency services the patient was defibrillated twelve times to treat ventricular fibrillation. She was admitted to a Stuttgart hospital at about 7:20 p.m. Resuscitation continued for one hour.

On admission the patient was intubated and given artificial respiration. Lidocaine and catecholamines were given by infusion. Bp was 100/60. Pupils medium wide in normal light; patellar tendon reflexes bilaterally equal. Babinski negative bilaterally. Extremities flaccid, with occasional twitching and fasciculation, esp. in the face. Laboratory values in normal range, except for serum potassium (3.6). Radiologically heart and lungs n.a.d. Fracture of the llth left rib due to resuscitation, but no pneumofhorax.Neurological examination on 5 July 1991 showed no reaction to pain, acoustic or optic stimuli. The eyeballs wandered to and fro, reaction to light was normal, ciliospinal reflex negative. Extremities showed both extensor and flexor spasticity. This indicated an acute midbrain syndrome (Benedikt). Among other things dexamethasone was given to treat the cerebral edema.

On 10 July 1991 (7th day of treatment) trial extubation. Danger of aspiration, bronchial spasms and deterioration of blood gas values due to respiratory depression made it necessary to intubate her again 18 hours later and continue SIMV.

On 14 July 1991 (llfh day of treatment) bradycardia of up to 45/min. and tachycardia developed, with the systolic pressure going down to 88 mm Hg. Spontaneous respiration ceased and CMV became necessary. Pupils en- larged, non-circular, non-reactive; comeal, oculocephalic and ciliospinal reflexes absent. Passive movement of legs caused tonic muscular movement with supination. No autonomic reflexes.

On 17 July 1991 (14th day of treatment) CAT scan showed massive cerebral edema, with the subarachnoid space gone and compression of surface parts of the brain, with nothing to indicate hemorrhage. 30 minute EEC gave no indication of electrical activity in any lead, merely discrete artefacts.

Gynecological examinations up to this time had shown the pregnancy to be progressing on time and intact. The husband repeated his wish that the pregnancy should continue. No further steps were therefore taken to confirm and complete assessment of the reasons for the cerebral failure.

Problems arose especially with regard to me circulation. Systolic pressure would range between 70-80 mm Hg, requiring dobutamine hydrochloride and fluids. Polyuria indicative of diabetes insipidus also developed. This was treated by giving desmopressin acetate i.v., s.c., and later nasally, and DHT, 15 drops b.d. by gastric tube, resulting in stabilization of me fluid balance. The patient was also given prednisolone sodium hemisuccinate i.v., there being a strong suspicion of adrenocortical hypofunction.

Renal elimination of electrolytes was high, requiring high-level replace- ment (up to 250 mEq KC1 daily). Enteral tube alimentation was gradually built up. Cardiac arrhythmias were recurrent (ventricular extrasystoles and occasional ventricular bigeminy). Intercurrent bleeding from a stress ulcer responded to ranitidine hydrochloride. RBC concentrates were given five times. FUO with high white cell count was treated with cefotaxime sodium (Claforan) and mezlozillin sodium.

Four weeks after being admitted to hospital she had an episode of cyanosis and acrocyanosis lying on her left side. The condition improved rapidly with the patient put in the supine position. No cause was established.

On 8 August 1991 (35th day of treatment) the patient was moved to the Filderklinik, which has both intensive care and gynecologic units. After a time in the anesthesiological and surgical unit she was moved to the medical intensive care unit on 2 September 1991. On admission she was on controlled respiration. Neurologic examination showed no response to voice or pain stimuli, no comeal reflexes or pupillary reactions. Spastic contractions and movement of tissue masses were noted in the extremities, especially the legs.

As the pregnancy was progressing normally, we did not consider it ethically justifiable to do the further investigations given in the guidelines to confirm the diagnosis of cerebral failure. It was our aim and purpose to guide the pregnancy to the point where the child became viable.

Dominant aspects in the evolution were cardiovascular instability, metabolic imbalances, nutritional problems and recurrent infections.

The blood pressure varied enormously (70-180 mm Hg systolic), for no apparent reason. Hypotensive phases generally responded well to volume increases, placing in shock position, and catecholamines if required. Hyper- tensive phases were initially treated with verapamil hydrochloride i.v., later with magnesium given by i.v. infusion. The first such phase was adequately controlled by giving 40 mEq/24 h, later approx. 80 mEq/24 h were required.

For unknown reasons, phases of sweating occurred, some showing laterality. Sudden redness of one side of the body was another feature. Ventricular extrasystoles, sometimes bigeminal but more often supraven- tricular, often went as high as 200/min.; they were treated with Isoptin i.v.

Overall, a positive metabolic balance was the aim, because of the pyrexia and also because of the profuse sweats. To treat the marked polyuria, sometimes up to six liters/day, desmopressin acetate was continued, giving 1/2-3 ampules s.c. daily, depending on urinary volume and the central venous pressure which was generally maintained at between 8 and 17 cm water column.

Tracheotomy was performed the day after admission to the Filderklinik. Artificial respiration continued in CMV mode, with 02 saturation between 30 and 40%, and PEEP 3-5, so that the pC02 was between 30 and 33% and p02 approx. 100%.

Airways were aspirated at frequent intervals during the day, with regular bronchopulmonary lavage.

When the temperature rose (up to 39.8 degrees C) and further infection was suspected (raised white cell count and raised CRP levels) tracheal tubes, cen- tral access channels, arterial catheters were changed and sent away for bacteriological investigation. A full range of cultures was made of blood, tracheal and nasal secretions and urine. E. coli and Staphylococcus epidermidis were found in the blood, Acinetobacter, Staph. aureus, Enterobacter cloacae, Klebsiella pneumoniae and Pseudomonas in the tracheal secretion. Nasal se- cretions contained bacteria of the enterobacter group, the urine E. coli, enterococci and Candida parapsilosis. Depending on the current bacteriogram, a suitable antibiotic was chosen in consultation with the gynecologists. Radiological examinations were not done, to avoid radiation exposure for the fetus.

A mild hemolytic anemia (LDH generally slightly elevated at 400, bilirubin between 1 and 3 mg%) caused repeated decreases in Hgb levels, requiring RBC concentrates on eight occasions; Hgb levels were between 9 and 10 mg%.

Nutrition was a major problem. The aim was to provide 2000/3000 kcal/ day, part of it parenterally. Enteral nutrition was limited because, depending on the product used, dian-hea would make enteral feeds impossible for a number of days. Regurgitation and gastric stasis due to atony of the gastrointestinal tract were also frequent. All in all, the patient received approx. 2000 kcal parenterally, with the remainder given enterally as a rule.

Blood sugar levels showed marked fluctuation, frequently going above 3000 mg% and requiring insulin treatment. Repeated ultrasound examinations of the abdomen showed nothing abnormal.

The patient was also given 600 IU of heparin sodium per hour, digoxin (0.2 mg daily), aldosterone (0.5 mg ) and initially also prednisolone sodium hen-dsuccinate (10 mg b.i.d.), later 75-100 mg of hydrocortisone daily. 150 mg of L-thyroxine were given daily by gastric tube. Albumin substitution as required, also vitamins, folic acid and iron preparations. A test with cortico liberin (Corticobiss) had indicated secondary adrenal insufficiency.

Paracetamol suppositories were used to treat pyrexia. Depending on the patient's condition. Arnica 30x ampules, Ferrum ustum comp. trit, Geum urbanum Ix dil., Anaemodoron drops, Hepadoron tablets, Argentum 30x/Lachesis 12x ampules and Argentum 30x/Echinacea 6x amp. were given as required.

From 19 August 1991 (46th day of treatment) periods of hypothermia (down to 35 degrees C, rectally) developed. From the second half of September, autonomic reactions were more marked: profuse sweating increased. The blood pressure rose to 210 mm Hg systolic. Hypotensive phases also became more frequent, so that it became increasingly more difficult to change the patient's position. Supraventricular tachycardia with frequencies of up to 200/min. was more frequent.

From 23 September 1991 (81st day of treatment) 1-3 hour hypotensive episodes with marked sweating showed rising frequency. Even with catecholamines they became more and more difficult to control. Because of this instability, the regular fetal heart monitoring and gynecological checks were increased to several times a day.

On 26 September 1991 (84th day of treatment) catecholamine had to be given in high doses to deal with persistent hypotension. Uterine contractions increased, with the fetal heartbeat slowing down. The situation of the fetus improved once the catecholamines were discontinued, but the blood pressure went down again. It was no longer possible to change the patient's position, as this would immediately result in uncontrollable decreases in blood pressure.

At about 8 p.m. the fetal heart rate deteriorated again, and a caesarian had to be done at 9.30 p.m. A boy weighing 1165 g was delivered, with an Apgar score of 5-7-8-9. Following positive pressure ventilation (bag and mask) the child was intubated at age 4 minutes and transferred to the intensive neonate care unit at the Esslingen hospital complex. He was prematurely born in the 29th week. He remained in hospital until 13 December 1991. He was on a respirator until 4 October 1991 because of grade II/III RDS. Staphylococcus epidermidis sepsis later made it necessary to put him back on the respirator for another 11 days.

Considering the birth age of the infant, however, nothing unusual occurred. He was discharged weighing 2400 g.

The boy is now three years old and developing normally.

After the caesarian the patient's condition became increasingly less stable. Ventricular fibrillation developed suddenly at 1 a.m., requiring repeated defibrillation. Resuscitation was done because the husband was present. It was only on the following day that he was able to make the extremely difficult decision that there should be no further resuscitarion attempts. The next day (27 September 1991) systolic blood pressure did not go above 50 or 60 mm Hg, in spite of high catecholamine doses. The pulse rate was between 160 and 200/min. The temperature rose to 40 degrees C in the course of the day. A 30 minute ECG done in the morning showed a zero line. A 5 minute apnea test in the afternoon showed absence of spontaneous respiration. Extensor spasms occurred with increasing frequency during the afternoon, and the patient became anuric in the evening.

The patient died in asystole in the early hours of 28 September 1991 (86th day of treatment). For references, see following article.

Paolo Bavastro, M..D. Filderklinik D-70794 Filderstadt Germany