Ultra-low dose, short-interval indocyanine green for pediatric fluorescence-guided surgery: A multicenter evaluation

To evaluate the safety and fluorescence performance of an ultra-low-dose, short-interval indocyanine green (ICG) protocol in pediatric fluorescence guided surgery (FGS), and to compare dose and timing with pediatric publications.

A multicenter retrospective analysis of prospectively collected data from pediatric patients undergoing FGS with ICG at eight institutions between March 2021 and November 2025. Variables included demographics, target structures, ICG dosing, and timing, which were compared to established pediatric dosing guidelines: 0.25-0.5 mg/kg given 45-720 min prior to biliary imaging, and a bolus of 0.1-0.5 mg/kg for angiography and tissue perfusion.

In 28 cases, more than 89% of intraoperative visualizations were rated satisfactory. The median ICG dose for biliary imaging was 0.05 mg/kg (0.03-0.11), corresponding to a 60-90% reduction compared with published recommendations. Administration occurred 30-75 min before visualization (median 55 min), which is below the intervals reported in the pediatric literature (45-720 min). Biliary procedures achieved reliable delineation of the common bile duct and cystic structures, showing favorable visualization at lower levels than previously reported. Perfusion applications also produced effective fluorescence using 0.05 mg/kg.

This multicenter study demonstrated that very low doses of ICG administered at short intervals are safe and can be reliable for FGS in children. Clear imaging was achieved despite the use of lower doses and shorter timing than current guidelines recommend. These findings support the adoption of the lowest effective ICG dose in pediatric FGS.