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In the United States, approximately 40,000 children per year undergo congenital heart surgery, with a large variation in intraoperative and postoperative analgesic regimens. Postoperative pain continues to be an intense area of research in pediatric cardiac surgery, as children with congenital heart disease are prone to significant hemodynamic consequences related to inadequate analgesia. Although protocols and guidelines have been created with the goal of improving postoperative analgesia, they have relatively poor adherence and do not consistently demonstrate improved pain control in the literature. Recently, methadone has become a drug of interest for intra- and postoperative analgesia. Methadone's pharmacokinetics make it appealing for postoperative analgesia owing to its long duration of analgesia, relatively brief peak respiratory depressant effects, and its antagonism at the N-methyl-D-aspartate (NMDA) receptor. Initially studied in complex spine surgery, methadone has been shown to reduce the rates of postoperative pain and postoperative opioid use in cardiac surgery, bariatric surgery, and same-day surgeries. Subsequently, methadone has been introduced as part of a multimodal analgesic strategy for pediatric cardiac surgery, although there is a paucity of literature describing its dosing and safety in this population. The aim of this retrospective descriptive cohort analysis was to add to the limited body of knowledge surrounding the use of intraoperative methadone in pediatric cardiac surgery, specifically as it pertains to postoperative ventilator time, opioid requirements, and pain scores. Herein, we present a multiyear study in an older cohort which demonstrates the safe and effective use of relatively low dose methadone to facilitate intraoperative extubation with safe postoperative outcomes. Following Institutional Review Board approval (IRB #26835), a retrospective analysis of all pediatric cardiac surgeries completed between January 1, 2020 and December 21, 2024 was performed. Informed consent was waived for this study. This time frame was chosen due to the introduction of methadone into the pediatric formulary for intraoperative use in 2020. At this time, methadone was added to the intraoperative analgesia bundle which included fentanyl, morphine, hydromorphone, and acetaminophen. The administration and dosing of methadone during this study period were at the discretion of the pediatric cardiac anesthesiologist. Subsequently, all anesthetic records of patients who were 0-18 years of age and underwent cardiac surgery were reviewed for the use of intraoperative methadone, and those patients were included for further review. Patients were excluded from further analysis if they did not have a complete data set, if their surgery was cancelled, or if they were found to require mechanical ventilation at baseline. Demographic information, surgical procedures and times, and postoperative outcomes including pain scores, ventilator times, reintubations, postoperative opioid requirements, time until rescue opioid administration, and length of stay were collected and analyzed using Microsoft Excel (Version 2503). Pain scores were taken from the patient's chart either as a Numerical Pain Score (NRS) or The Face, Legs, Activity, Cry, and Consolability (FLACC) scale. Milligrams of morphine equivalency (MME) was calculated using the formula MME = (micrograms of fentanyl/1000) + (milligrams of hydromorphone×20). Morphine equivalents of methadone were not calculated due to the unpredictable nature of this conversion. Subsequently, a descriptive cohort analysis of all pediatric cardiac surgery patients who received intraoperative methadone was performed in Microsoft Excel and Minitab. An extensive literature review of methadone in pediatric cardiac surgery was conducted.