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  • Clinical Research Article
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Impact of ultrasound-guided circulatory management protocol on intraventricular hemorrhage in extremely preterm infants

Pediatric Research (2026)Cite this article

A Correction to this article was published on 19 March 2026

This article has been updated

Abstract

Background

Intraventricular hemorrhage (IVH) is a serious complication in extremely preterm infants, in whom the first 72 hours of life are critical. We evaluated the impact of an ultrasound-guided circulatory management protocol on IVH incidence.

Methods

This retrospective study included infants who were born before 28 weeks of gestation and admitted to a tertiary neonatal intensive care unit between January 2018 and September 2024. In June 2022, a new protocol was introduced that incorporated three daily ultrasound assessments, adequate and tailored sedation, and targeted nitroglycerin use guided by ultrasound hemodynamic findings. Clinical outcomes and blood pressure trends were compared between the pre- and post-implementation groups.

Results

Ninety-two infants (49 pre-implementation and 43 post-implementation) were analyzed. The incidence of overall IVH decreased from 37% to 9% (p = 0.002), and severe IVH declined from 16% to 2% (p = 0.03). After implementation, increases in blood pressure were slower, and variability was reduced. No increase in hypotension duration or adverse outcomes was observed.

Conclusion

After the implementation of the ultrasound-guided circulatory management protocol, the IVH incidence significantly decreased. These findings also support the potential of ultrasound by neonatologists in the circulatory management of extremely preterm infants.

Impact statement

  • An ultrasound-guided circulatory management protocol reduced the incidence of intraventricular hemorrhage in extremely preterm infants.

  • The protocol included frequent cardiac and cranial ultrasound assessments, adequate and tailored sedation, and selective nitroglycerin use guided by real-time ultrasound hemodynamic findings.

  • After implementation, blood pressure rose more gradually and fluctuated less, indicating improved hemodynamic stability.

  • These findings support a feasible, individualized approach to protect the immature brain during the most vulnerable period.

  • The study also highlights the potential role of ultrasound by neonatologists in optimizing the care for extremely preterm infants.

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Fig. 1: Measurement of internal cerebral vein (ICV) flow patterns.
Fig. 2: Comparison of mean blood pressure during the first 72 h.

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Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Change history

  • 16 March 2026

    The original online version of this article was revised: In the section ‘Circulatory management protocol’, the term ‘μg/kg/h’ should have read ‘μg/kg/min’.

  • 19 March 2026

    A Correction to this paper has been published: https://doi.org/10.1038/s41390-026-04922-8

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Acknowledgements

We would like to express our sincere gratitude to Dr. Jiro Takeuchi, and Dr. Kyoko Sakai, Institute for Clinical and Translational Science, Nara Medical University Hospital, for the valuable clinical-epidemiological advice. We thank Anahid Pinchis, B.Sc., MBA, from Edanz (https://jp.edanz.com/ac), for editing a draft of this manuscript.

Funding

No financial assistance was received in support of the study.

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Authors and Affiliations

  1. Division of Neonatal Intensive Care, Center of Perinatal Medicine, Nara Medical University Hospital, Kashihara, Japan

    Hirosato Aoki, Tomoyuki Kamamoto, Ayaka Ohara, Kazuki Shimizu, Masateru Onishi, Tetsunori Kakutani, Akiko Masaki, Yuki Tani, Eri Nishimoto, Hitoshi Tonegawa, Toshiya Nishikubo & Yumiko Uchida

  2. Institute for Clinical and Translational Science, Nara Medical University Hospital, Kashihara, Japan

    Naoki Ozu

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  1. Hirosato Aoki
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  2. Tomoyuki Kamamoto
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Contributions

H.A., N.O. concepted the design, analysis, and interpretation of the data. H.A., T.K., A.O., K.S., M.O., T.K., A.M., Y.T., E. N., H.T., T.N., and Y.U. contributed to data acquisition. H.A. drafted the initial manuscript. All authors critically revised the manuscript critically and approved the final version.

Corresponding author

Correspondence to Hirosato Aoki.

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Competing interests

The authors declare no competing interests.

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Consent was obtained via opt-out because this study is a retrospective observational study.

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The original online version of this article was revised: In the section ‘Circulatory management protocol’, the term ‘μg/kg/h’ should have read ‘μg/kg/min’.

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Aoki, H., Kamamoto, T., Ozu, N. et al. Impact of ultrasound-guided circulatory management protocol on intraventricular hemorrhage in extremely preterm infants. Pediatr Res (2026). https://doi.org/10.1038/s41390-026-04863-2

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