A reply

We thank Dr Ralph for her interest in our work [1]. We have used intra-operative cell salvage during operative obstetric interventions since 2006, and as routine practice since 2010. However, autologous blood does not contain any clotting factors, so the risk of coagulopathy is not removed, hence the rationale for our paper. Since publication, we have analysed a further year’s data (July 2013 – June 2014) and have been able to estimate the financial benefit of using fibrinogen concentrate (Table 1). The cost of the ROTEM machine is ~£25 000 to purchase outright (although other options may be available from the manufacturers), with disposables costing £28 in total for one EXTEM + one FIBTEM test. There is a common perception that because the unit price of fibrinogen concentrate is around £340.g 1 (personal communication, CSL Behring, Marburg, Germany 10/09/2014), it is prohibitively expensive to use. However, Table 1 shows that this cost is offset by a reduction in the cost of blood products used, such that overall, the median cost per patient is reduced (if not significantly) when a ROTEM-guided fibrinogen concentrate algorithm is used. We did not factor into our analysis the cost savings associated with reduced complication rates through reduced usage of blood components. These figures make sense for our unit, taking into account our size and the complexity of our casemix. We would suggest that Ralph will need to extrapolate our figures to her own unit to see if a business case using our data will stand up to scrutiny, given the slightly different nature of our respective units. We agree that using a more restrictive transfusion trigger may be helpful, with postoperative oral or intravenous iron therapy, but in practice, this involves the cooperation of our obstetric colleagues and hence their conversion to this way of thinking. We would like to commend Ralph and colleagues for their excellent use of cell salvage. Achieving a return of salvaged blood in