OBJECTIVES: Perioperative red cell salvage (CS) – the process of collecting shed blood during surgery and returning it to patients - reduces the need for allogeneic blood transfusion, which results in fewer transfusion-related adverse events and consequently more quality-adjusted life years compared to surgery without CS. However, little is known about the cost of CS in pediatric surgery. Our objective was to compare the societal costs associated with four transfusion strategies among patients undergoing elective orthopedic or cardiac surgery in Children’s Hospital Boston: 1) CS followed by autologous transfusion; 2) CS followed by allogeneic transfusion; 3) autologous transfusion alone; and 4) allogeneic transfusion alone. METHODS: A TreeAge © decision tree was used to conduct all comparisons (2010 dollars), threshold analyses, univariate and multivariate probabilistic sensitivity analyses. The CS-related and blood processing direct, indirect and labor costs/patient were obtained from the hospital accounting records and the cost of a unit of red blood cells (RBC), from nationally representative reports. Probabilities of blood transfusion after CS and the number of RBC units returned via CS were obtained from hospital utilization records. The probabilities and lifetime costs of a range of infections and reactions caused by allogeneic transfusion were derived from published sources. RESULTS: Average CS, blood processing and RBC unit costs were $160, $1895 and $223, respectively. Average volume of blood returned via CS was 271cc, and the probability of needing transfusion after CS was 0.80. Cell salvage with autologous blood transfusion ($1504) was least expensive, followed by CS with allogeneic transfusion ($1512), autologous ($1899) and allogeneic transfusion ($1906) with differences persisting in sensitivity analyses. Cell salvage resulted in net savings at a threshold of ≤ $556/patient. CONCLUSIONS: Use of CS, particularly with autologous blood pre-donation appears cost-saving and cost-effective in pediatric surgery and should be encouraged.