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Point-of-care ultrasound (POCUS) has dramatically changed and improved the way high acuity clinician situations are managed in the operating room, emergency department and ICU setting. The widespread availability of ultrasound technology has increasingly enabled its use as a bedside diagnostic and procedural tool, supporting rapid clinical assessment and enhanced procedural precision. Contemporary physician trainees now develop point-of-care ultrasound (POCUS) skills as a core competency, while clinicians trained in earlier eras are progressively incorporating POCUS into established practice. As POCUS use expands in pediatric care, we outline foundational concepts to help pediatric clinicians begin integrating POCUS into their daily practice ( Fig. 1 ) .

Core pediatric POCUS exam.

Reproduced with permission from baby-blocks.com .

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Point-of-care lung ultrasound (LUS) is an established imaging modality. To the pediatric clinician it is useful to assess for pneumothorax, effusion, consolidation, and edema. Furthermore, LUS is incredibly sensitive at diagnosing endobronchial intubation, which may be a desired or undesired outcome depending on the clinical situation, and can facilitate the appropriate placement of a chest tube when indicated.

To begin, it is worth remembering that the normal lung is a largely air-filled structure composed of air spaces, a rich microvascular network, and interstitium. The difference in acoustic impedance between these components generates sonographic artefacts that can then be interpreted. The lungs are situated deep to the ribcage so in older children, acoustic widows must be found, typically between ribs, through the abdomen, or at the supraclavicular fossa. In neonates and infants, it may be possible to acquire transcostal images due to the more cartilaginous and less mineralized nature of their ribs (see Fig. 2 ) . Further, it is important to remember that for a comprehensive assessment it is necessary to image as much of the chest as possible; a sonographic image at a single location only reveals what is present (or absent) at that location.

Transcostal imaging highlighting ultrasound penetrability in pediatric patients across age groups. Reproduced with permission from baby-blocks.com .

Subcostal four-chamber view illustrating relevant anatomy, sonoanatomy, and ultrasound screen visualization. Reproduced with permission from baby-blocks.com .

RA = right atrium, RV = right ventricle, LA = left atrium, LV = left ventricle.

The basics of LUS are essentially the same across age groups, from neonate to geriatric, and much has been published on image acquisition and interpretation (see Table 1 ) . In this focused review, we highlight two uses considered as essential skills for any pediatric clinician managing high acuity clinical situations. For these assessments we recommend the use of a high frequency linear probe. Perhaps counterintuitively, while smaller probes are generally employed for pediatric applications, a larger footprint probe allows for more lung field to be imaged per screen, facilitating a more efficient exam.

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Cardiac Point-of-Care Ultrasound (POCUS) is a valuable tool for a quick assessment of cardiac structures and function, especially in critical situations. While not comprehensive, it can be useful in diagnosing acute conditions, such as hypotension, shock and circulatory arrest. If any structural abnormality suggestive of congenital heart disease (CHD) is suspected or visualized while performing an exam, a formal echocardiogram should be performed by a pediatric cardiologist ^,,,,.

Although infrequently used perioperatively in pediatric patients, its preoperative application can be particularly advantageous when there are concerns regarding systolic function, significant valvular disease, or a hemodynamically significant pericardial effusion ^,,,. Several studies demonstrate its that after brief training, cardiac POCUS can identify ventricular abnormalities and pericardial effusions with accuracy exceeding 90 % ^,. It’s use in pediatric cardiac arrest has also been studied, showing it aids in diagnosis of critical CHD and helps guide resuscitative efforts . While still primarily embraced by enthusiasts and early adopters in pediatric anesthesiology, the benefits seem clear, especially when a single view may be sufficient to evaluate for a pathology of interest (e.g. pericardial effusion) .

The greatest value of cardiac POCUS in the perioperative setting may be in the preoperative phase, particularly when there is concern about systolic function, severe valvulopathy, or evidence of pericardial effusion . When performing cardiac POCUS in children, selecting the appropriate probe is essential. Higher frequency probes with small footprints may be ideal in visualizing cardiac structures between small rib spaces.

Because pediatric patients may be less cooperative, cardiac POCUS examinations should be used to confirm findings rather than to exclude pathology . Scans should be concise and targeted, focusing on the specific clinical question—especially in emergent or unstable situations. Whether using an in-house protocol or the I-AIM model (indication, acquisition, interpretation, and medical decision-making), the scan should ideally be limited to five to 7 min . .

Probe selection should always be tailored to the child’s size. Cardiac POCUS typically uses B-mode imaging with a high-frequency probe and a small footprint. Larger probes may prevent optimal scanning between rib spaces.

There are five principal views used for a cardiac POCUS examination: the subcostal (subxiphoid) four-chamber view (S4C), subcostal IVC view, parasternal long-axis view (PLAX), parasternal short-axis view (PSAX), and apical four-chamber view (A4C).

• A.Subcostal Four-Chamber View (S4C) (see Fig. 3 )

  The S4C view visualizes the heart in an oblique orientation, allowing assessment of global biventricular systolic function, valvular abnormalities, and pericardial or pleural effusions. Apply firm pressure, nearly flattening the transducer against the abdominal wall, and orient it parallel to the wall, as if holding a screwdriver.

  To obtain this view, place the probe under the xiphoid process with the indicator at 3 o’clock (toward the left flank), centering over the cardiac crux and aligning the apex to the right side of the screen. Slide slightly toward the patient’s right side if needed for better visualization. Having the child take a deep breath may help improve the view in cooperative patients.

• B.

  Subcostal IVC View

  This view allows qualitative assessment of the inferior vena cava (IVC) diameter and collapsibility just below the diaphragm. However, its utility for estimating intravascular volume in children remains limited. (11) Center the probe over the intrahepatic IVC as it enters the right atrium (which appears on the right side of the screen). The transducer is subxiphoid, with the indicator at 12 o’clock (toward the head). Typically, only probe angulation—not sliding—is needed to acquire this image.

• C.

  Parasternal Long-Axis View (PLAX)

  The PLAX view provides detailed visualization of the left ventricle, aortic root, mitral valve, and surrounding structures. It is useful for assessing left ventricular size and function, detecting pericardial effusion, and evaluating the mitral and aortic valves with color Doppler. In the normal heart, the left atrium, aortic root, and right ventricular outflow tract (RVOT) should appear roughly equal in dimension (1:1:1).

  To obtain this view, position the indicator at 10 to 11 o’clock (toward the right shoulder) just left of the sternum, ideally with the patient in the left lateral decubitus position. Center the probe over the mitral valve with the left ventricular apex on the left side of the screen. Adjust depth to include the descending aorta.

  If the apex seems tilted upward, indicating proximity to the apex, adjust by moving the probe up a level or two. If the left ventricle appears foreshortened, rotate slightly to correct the angle. If the valves are off-center, tilt away from the sternum. For advanced imaging, posterior angulation shows the tricuspid valve and right ventricular inflow, while anterior angulation visualizes the pulmonary valve and outflow tract. In infants, the entire heart can often be imaged without moving the probe; in older children, slight lateral adjustment may be necessary.

• D.

  Parasternal Short-Axis View (PSAX):

  The PSAX view visualizes the heart in cross-section, allowing evaluation of ventricular size, wall motion, and valvular morphology. Sweeping from the base of the heart to the apex provides transverse images at the aortic, mitral, and papillary muscle levels. Pericardial effusions can also be identified in this view. Flattening of the interventricular septum indicates right ventricular volume or pressure overload.

  To acquire this view, place the indicator at 1 to 2 o’clock (toward the left shoulder) and center over the left ventricle at the papillary muscle level. The left ventricle should appear round and centered. If it looks pear-shaped, move one intercostal space higher; if asymmetric, rotate clockwise or counterclockwise until it becomes round. In larger children, one may have to move the probe down one rib space to complete the full sweep.

• E.

  Apical Four-Chamber View (A4C)

  The A4C view visualizes the heart along its long axis from the apex, displaying all four chambers at full length. It allows comparative assessment of left and right ventricular size, evaluation of atrioventricular valves, and identification of pericardial effusion. Significant mitral or tricuspid regurgitation can be detected using color Doppler.

  To obtain this view, slide the probe caudally from the PSAX position until the apex comes into view, then tilt the transducer upward to bring all four chambers into their longest cross-section. Alternatively, one can place the probe just below the fifth intercostal space, ideally with the patient in a left lateral decubitus position. The indicator should point toward 5 o’clock. Tilt the transducer superiorly until all four chambers are visible.

  If the atria are not visible, tilt upward; if the heart appears rotated leftward, move laterally. To avoid left ventricular foreshortening, ensure imaging is at the true apex, showing the normal bullet shape. In some cases, moving one intercostal space lower and laterally may help. Sweeping posteriorly will show the coronary sinus, while sweeping anteriorly provides the five-chamber view, allowing visualization of the left ventricular outflow tract and ascending aorta.

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Gastric ultrasound, a developing field, is primarily used to assess gastric contents before anesthesia to reduce the risk of aspiration. Despite low pulmonary aspiration rates in pediatrics, targeted evaluation of gastric content can provide valuable safety information and reassurance in select cases ^,.

In pediatric anesthesia, mask induction remains the standard approach for patients under ten years of age. However, non-adherence to fasting (NPO) guidelines remains a recurring challenge, particularly among children with communication barriers or developmental delays. Reported pediatric non-compliance rates of approximately 13% highlight the potential risk of inadvertent food intake and aspiration . Fortunately, the incidence of pulmonary aspiration in children is are, reported as low as 0.04–0.1 % ^,, As international societies continue to reevaluate and liberalize fasting recommendations, clinical adaptability is increasingly essential. In response, a consortium of pediatric anesthesia experts now endorses the use of gastric ultrasound for children undergoing elective or emergency surgery. This proactive, evidence-based approach to assess gastric contents and improve perioperative safety when fasting status is uncertain .

The European Society of Anesthesiology and Intensive Care selected a panel of expert members from the European Society for Pediatric Anesthesiology, the Canadian Pediatric Anesthesia Society, and the Society for Pediatric Anesthesia to develop updated guidelines for preoperative fasting in children. These recommendations include the use of ultrasound to assess gastric contents and volume in children scheduled for elective surgery when fasting instructions have not been followed, and in children presenting for emergency surgery .

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Position and image acquisition

The patient should be ideally scanned in both the supine and the right lateral decubitus position. The head of the bed should be elevated 30–45°. Scanning in both positions allows for assessment of changes in antral shape and content distribution with gravity, improving the accuracy of gastric content characterization. Since children may only cooperate for short periods of time, choosing only right lateral decubitus position may be more efficient ( Fig. 4 ).

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