Laryngoscopy, intubation and extubation are very stimulating times. The sympathetic pressor response can be dangerous in certain patients and conditions. There are ways to obtund this pressor response:

• IV lidocaine 1.5 mg/kg given 3-5 min prior to induction
• IV alfentanil 10-20 μg/kg immediately prior to induction
• IV magnesium 40 mg/kg immediately after induction (bolus injection is painful in the awake patient)
• IV remifentanil bolus
• IV esmolol

Spraying the vocal cords with local anaesthetic will obtund the response to intubation only. It may be possible to avoid intubation in the first place by using an alternative airway device, such as the laryngeal mask airway.