Indocyanine green beyond quantitative liver function tests – An adjuvant in pediatric imaging

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Indocyanine green (ICG) is a nontoxic, inert, anionic water-soluble tricarbocyanine dye with ability to fluorescence when light of the near infrared spectrum is focused onto it with a customized camera. ICG has been known as a diagnostic agent for decades. As with many diagnostic modalities in the medicine, the use of ICG has slowly expanded to find varied and novel applications in the clinical practice. Its use as an imaging modality in pediatric surgery is only increasingly being recognized. The uses of ICG range from bile duct identification, biliary atresia surgery, bowel ischemia delineation, tumor detection, parathyroid identification, and lymph leak detection to name a few. Its safety profile, property to bind to plasma proteins, and be excreted exclusively in the bile make it ideal for intraoperative pediatric surgical imaging. Data on ICG use in children are limited to a handful of case reports and few case cohorts globally. A broad literature search on the history of ICG use, pharmacology, licensing applications, and clinical reports specifically for pediatric populations was carried out. This review was done with intent to analyze the safety profile and compile the various indications of ICG use in children. The dye finds ever expanding clinical uses in our large tertiary referral unit for children in NSW, Australia, and it was our intent to create a protocol that allows for its safe use in routine clinical practice. This protocol created will benefit not only our patients, but is one that can be adopted for other pediatric surgical services worldwide.