POCUS-assisted catheterization increases first-attempt success to 89.7% versus 72.5% in children under 36 months

BACKGROUND: Urethral catheterization is the standard method for obtaining sterile urine in nontoilet-trained children, but the conventional blind technique frequently results in futile attempts ("dry taps") on empty bladders. Point-of-care ultrasound (POCUS) offers the clinical advantage of confirming adequate urine volume to prevent mucosal trauma and procedural distress. However, its routine implementation may be limited by operator training requirements and potential workflow delays while waiting for bladder filling. Therefore, this study aims to evaluate the efficacy of real-time POCUS-assisted versus standard blind urethral catheterization in pediatric patients. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) adhering to PRISMA guidelines (PROSPERO: CRD420251247483). We searched PubMed, Embase, and CENTRAL for trials comparing POCUS-guided versus standard catheterization in children aged ≤ 36 months. The primary outcome was the first-attempt success rate. The certainty of evidence was evaluated using the GRADE approach. RESULTS: Three trials comprising 337 participants were included. POCUS-assisted catheterization significantly increased first-attempt success compared to the conventional technique (89.7% vs. 72.5%; RR 1.25, 95% CI 1.08-1.45, p = 0.0022), yielding a Number Needed to Treat (NNT) of 6. Furthermore, ultrasound guidance significantly reduced the rate of "dry taps" (3.6% vs. 23.9%; RR 0.25, 95% CI 0.13-0.47, p < 0.0001), representing an NNT of 5 to prevent one futile attempt. The certainty of evidence for the primary outcome was rated as moderate. Secondary descriptive outcomes indicated higher caregiver satisfaction, lower perceived patient discomfort, and comparable overall workflow times despite required waiting periods for bladder filling. CONCLUSIONS: Real-time POCUS significantly improves first-attempt catheterization success and drastically reduces futile attempts in young children. Furthermore, it enhances caregiver satisfaction and minimizes patient distress without intrinsically delaying emergency department workflow. These highly actionable findings support the integration of ultrasound guidance into routine pediatric emergency care.