OBJECTIVE This study was designed to compare the effectiveness of remifentanil vs. a lidocaine-esmolol combination in blunting the hemodynamic response to laryngoscopy and intubation during rapid sequence induction using thiopental and rocuronium in normotensive patients. METHODS Sixty-six patients with American Society of Anesthesiologists (ASA) physical status class I who required tracheal intubation for elective surgery were randomly assigned to one of two groups. Group R received 0.9% saline 10 ml and remifentanil 1 microg/kg. Group LE received lidocaine 1.5 mg/kg and esmolol 1.0 mg/kg. Anesthesia was induced with thiopental sodium 5 mg/kg, followed by rocuronium 1.0 mg/kg. Mean arterial pressure and heart rate were recorded at baseline, after induction, immediately after intubation and every minute for five minutes after intubation. RESULTS Changes in mean arterial pressure over time between the two groups were significantly different (P<0.0001). The maximum pressor response was observed immediately after intubation, at which time the mean arterial pressure change from baseline in group LE (29.7%) (95% confidence interval [CI]: 116.1, 121.9) was higher than that in group R (4.4%) (95% CI: 92.9, 98.5) (P<0.0001). Two patients in group R and 15 patients in group LE developed hypertension (odds ratio [OR]: 0.064) (P<0.001). Changes in heart rate over time between the two groups were not significantly different (P=0.465). CONCLUSIONS The results of this study show that remifentanil 1 mg/kg is more effective than the combination of lidocaine 1.5 mg/kg and esmolol 1 mg/kg for attenuating the hemodynamic responses to rapid sequence intubation.