We appreciate the author's feedback. We have discussed their comments with our primary bariatric anesthesia group. Based on their clinical experience, 30 years in one case, they do not believe lidocaine to be very effective in eliminating the fasciculations from succinylcholine (SUX), and consequently postoperative myalgias. Rocuronium (ROC), on the other hand, is effective in eliminating the fasciculations, but it is painful on injection which is not easily prevented by lidocaine. They still prefer using ROC or other nondepolarizing agents for rapid sequence inductions with complete success. The difference in onset between SUX and ROC is 1–2 min which they consider trivial compared to the time taken to accomplish the intubation. Furthermore, if one prevents active vomiting by excellent anesthesia and paralysis, and passive regurgitation by “correct” cricoid pressure, then the amount of time required for intubation is no longer critical. To quote them directly: “The word ‘rapid’ in rapid sequence induction is one of the worst words in the lexicon of anesthesia”. Their preference is for “safe sequence inductions” so that time is no longer relevant.

From a surgeon's standpoint, the additional side effects of SUX (as outlined in our paper) are of equal concern in this particular patient population. We agree that one case may not define the entire practice. However, when better drugs are available with a more favorable overall profile, we also don't see the need to use SUX instead of ROC.