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The venous excess ultrasound score (VExUS) is a promising method to assess venous congestion in adults, but evidence in children is scarce. This study aimed to evaluate the feasibility, reproducibility, and clinical usefulness of VExUS in pediatric patients. We also explored whether portal venous Doppler (PVD) alone could serve as a faster alternative and assessed the role of inferior vena cava (IVC) measurements. In this prospective single-center study, 35 pediatric patients were enrolled between 2022 and 2024. Associations between clinical variables and VExUS grades at admission (VExUS-0), 24 h (VExUS-24 h), and 48 h (VExUS-48 h), as well as PVD at corresponding time points, were analyzed. The relationship between IVC diameter and VExUS was also evaluated. VExUS demonstrated perfect reproducibility (κ coefficient and intraclass correlation coefficient = 1). Patients with VExUS-0 or VExUS-24 h grades 2-3 had longer aortic cross-clamp times (p = 0.03; 0.04) and higher vasoactive-inotropic scores (p = 0.01) than those graded 0-1. A higher incidence of acute kidney injury was observed in VExUS-24 h grades 2-3 (p = 0.04). Similar associations were found with PVD. Most patients with VExUS grades 2-3 had non-dilated IVCs according to pediatric reference values.

 VExUS is a feasible, reproducible, and clinically relevant bedside tool for detecting venous congestion in children. Its association with morbidity markers suggests prognostic potential, with optimal performance 24 h after PICU admission. PVD may provide comparable information in less time, while IVC diameter appears unreliable for this purpose.

• VExUS enables bedside assessment of venous congestion and is associated with adverse outcomes in adults, particularly after cardiac surgery. • However, pediatric evidence is limited, and its clinical applicability remains uncertain.

• This study shows that VExUS is feasible, reproducible, and associated with morbidity after pediatric cardiac surgery, with the highest prognostic value at 24h. • Portal Doppler may provide comparable performance, whereas IVC diameter is is not a reliable marker of venous congestion in this population.