Background: No consensus exists on the management of hemodynamic impairment in very premature neonates. At level 3 NICU, the protocol involves an initial infusion of crystalloids, followed by a cardiac ultrasound if the infusion fails to restore appropriate hemodynamics. Based on the ultrasound findings, a decision is then made regarding a second infusion or the prescription of vasopressor amines. The aim of the present study was to assess the effect of and compliance with this management practice in neonates born prematurely between 26 and 31 completed weeks of gestation following a plan-do-study-act design. Methods: Data were collected retrospectively from patient records for all neonates who were managed for hemodynamic impairment within the first 24 h of life. Results: Of 604 neonates born during the study period, 68 were included in this study, but only eight cases followed the protocol. Reasons for non-compliance were the absence of cardiac ultrasound and variations in the duration and dosage of fluid administration. There was a significant relationship between blood pressure and positive inspiratory pressure levels at the time of management and compliance with the protocol. Conclusions: A revision of the protocol will emphasize the importance of echocardiography assessment, as all neonates responded to the ultrasound-guided therapy. As a quality improvement measure, attending neonatologists will be trained to thoroughly adhere to the protocol before the next evaluation.