Background <p>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.</p> Methods <p>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.</p> Results <p>Ninety-two infants (49 pre-implementation and 43 post-implementation) were analyzed. The incidence of overall IVH decreased from 37% to 9% (<i>p</i> = 0.002), and severe IVH declined from 16% to 2% (<i>p</i> = 0.03). After implementation, increases in blood pressure were slower, and variability was reduced. No increase in hypotension duration or adverse outcomes was observed.</p> Conclusion <p>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.</p> Impact statement <p><UnorderedList Mark="Bullet"> <ItemContent> <p>An ultrasound-guided circulatory management protocol reduced the incidence of intraventricular hemorrhage in extremely preterm infants.</p> </ItemContent> <ItemContent> <p>The protocol included frequent cardiac and cranial ultrasound assessments, adequate and tailored sedation, and selective nitroglycerin use guided by real-time ultrasound hemodynamic findings.</p> </ItemContent> <ItemContent> <p>After implementation, blood pressure rose more gradually and fluctuated less, indicating improved hemodynamic stability.</p> </ItemContent> <ItemContent> <p>These findings support a feasible, individualized approach to protect the immature brain during the most vulnerable period.</p> </ItemContent> <ItemContent> <p>The study also highlights the potential role of ultrasound by neonatologists in optimizing the care for extremely preterm infants.</p> </ItemContent> </UnorderedList></p>