Cardiorespiratory Collapse During Routine Endoscopy
A Case Analysis of Monitoring Failure and Delayed Resuscitation During Propofol Sedation
Case Law Index · Monitoring Failure · Resuscitation Delay
TL;DR
57 y/o woman undergoes a routine outpatient ERCP under propofol sedation. At the close of the 15-minute procedure, she suffers cardiorespiratory collapse — her heart rate plunges to 27 bpm and oxygen saturation craters. The anesthesia team fails to recognize the severity of the event, does not initiate chest compressions, and delays calling a code. She is left with a devastating anoxic brain injury and dies one month later in the ICU. A New Haven jury returns a verdict of $15.4 million.
Context
The Patient
Maria Ocasio, 57 y/o female. A grandmother of seven, born in Puerto Rico. Specific comorbidities are not disclosed in the public record, but she presented for an elective outpatient biliary procedure — consistent with a patient carrying baseline gastrointestinal pathology.
The Procedure
Scheduled endoscopic retrograde cholangiopancreatography (ERCP) at MidState Medical Center in Meriden, CT. ERCP is a combined endoscopic and fluoroscopic procedure used to diagnose and treat disorders of the biliary tract and pancreatic duct. Compared to a standard EGD, ERCP is technically more demanding, typically longer in duration, and is performed with the patient in the prone position — a configuration that independently increases the risk of airway compromise and ventilatory difficulty under sedation.
Anesthesia Plan
Monitored Anesthesia Care using propofol, administered in repeated single-dose boluses. Anesthesia care was provided by CRNA Ruey under the supervision of Dr. Guy J. Aliotta of the Meriden-Wallingford Anesthesia Group. As with most outpatient GI endoscopies, the airway was not secured with an endotracheal tube — the endoscope occupies the oropharynx, making intubation both anatomically impractical and procedurally disruptive in this context.
Timeline
March 2017
Procedure Initiated
ERCP initiated. Propofol administered as multiple single-dose boluses to achieve and maintain MAC-level sedation. Procedure was expected to take approximately 15–20 minutes. No endotracheal tube placed; airway unprotected.
End of Procedure
Cardiorespiratory collapse occurs. SpO₂ plummets. Heart rate drops to 27 bpm. The anesthesia team does not initiate chest compressions. No code is called. The supervising anesthesiologist, Dr. Aliotta, does not take emergency resuscitative action despite the severity of the hemodynamic deterioration, this is due to the failure to recognize severity.
Post-Arrest
Ocasio is eventually resuscitated but has sustained a severe anoxic brain injury secondary to the prolonged period of cerebral hypoperfusion. She is admitted to the ICU in a critically compromised neurological state, mechanically ventilated, unresponsive.
~1 Month Later
Maria Ocasio dies in the ICU. She never regained meaningful neurological function following the anoxic insult. She is survived by her children and seven grandchildren.
Mechanism of Injury
Pharmacodynamics
Propofol was administered as repeated bolus injections rather than a controlled infusion — a technique that produces pronounced peak plasma concentration spikes with each dose, increasing the likelihood of overshooting the sedation target and crossing into general anesthetic depth.
- Propofol (bolus dosing): Each bolus produces a transient but steep rise in effect-site concentration at the CNS. Repeated dosing without adequate inter-dose intervals does not allow for redistribution and can drive cumulative depression of both the respiratory center and the cardiovascular system — the latter manifesting as bradycardia and hypotension through inhibition of sympathetic tone and direct myocardial depression.
- Prone positioning: ERCP is commonly performed with the patient prone or in the left lateral decubitus position. Prone positioning reduces functional residual capacity (FRC), increases the work of breathing, and limits the anesthetist’s ability to visually assess chest rise and access the airway rapidly in the event of an emergency — all factors that compound the risk of unrecognized hypoventilation under sedation.
Pathophysiology
Propofol overdose suppresses the medullary respiratory center and blunts the hypercapnic ventilatory response, leading to progressive hypoventilation and apnea. As PaO₂ falls and PaCO₂ rises without correction, hypoxemia drives a vagally-mediated bradycardia. In this case, the heart rate dropped to 27 bpm — indicative of a profound vasovagal or hypoxia-mediated bradycardic event. Failure to initiate immediate BLS (chest compressions, airway rescue) allowed continued cerebral hypoperfusion. The brain tolerates global ischemia for approximately 4–6 minutes before irreversible neuronal death begins; extended periods of inadequate cerebral oxygen delivery translate directly into the anoxic encephalopathy Ocasio suffered.
The Law
The Breach
The Ocasio family’s complaint alleged the following departures from the standard of care:
- Administration of excessive propofol doses without adequate titration, driving the patient below MAC depth into a state of general anesthetic-level CNS and respiratory depression.
- Failure to properly monitor vital signs — specifically, failure to recognize the clinical significance of a rapidly declining heart rate and oxygen saturation at the conclusion of the procedure.
- Failure to initiate timely emergency resuscitation: no chest compressions were begun, and a code was not called despite a bradycardic event severe enough to constitute a perioperative cardiac arrest.
- Inadequate supervision by Dr. Aliotta, who failed to appropriately oversee CRNA Ruey’s administration and did not take control of the emergency in a clinically reasonable timeframe.
The Outcome
On July 3, 2024, a New Haven, CT jury found in favor of the estate of Maria Ocasio against the Meriden-Wallingford Anesthesia Group and the estate of Dr. Guy J. Aliotta (who passed away in 2021). Damages were awarded across three categories:
- Loss of Enjoyment of Life: $1,000,000
- Pre-Death Pain and Suffering: $5,000,000
- Wrongful Death: $9,400,000
- Total Judgment: $15,400,000
Note: The plaintiffs had offered to settle for $2 million prior to trial. The defense declined. The jury returned a verdict 7.7× higher than the settlement demand.
Reflection
The defining failure in this case was not the administration of propofol itself — it was the absence of a timely rescue response once the patient decompensated. A heart rate of 27 bpm is not a subtle finding requiring interpretation; it is a cardiovascular emergency demanding immediate action. Chest compressions and code activation are not advanced clinical judgments — they are foundational emergency responses. For anesthesia providers, this case underscores that sedation without a secured airway demands relentless vigilance, and that the threshold for escalation must be low, immediate, and unconditional. The cost of hesitation is measured in minutes of cerebral ischemia — and millions of dollars in the courtroom.
References