We thank Prof Mirakhur et al. for their valuable comments. In our manikin study, we decided that the clinical scenario was a ‘cannot intubate, cannot ventilate’ situation and that sugammadex reversal was needed. This was clearly defined as the start point of the study. The simulated patient had a body mass index > 35 kg.m−2, so severe oxygen desaturation could have occurred rapidly, even after proper pre-oxygenation. We found it took, on average, 6.7 min to administer sugammadex intravenously. The teams had many problems including: difficulty finding the correct drug from the storage room; calculation errors; time lost preparing the drug; and human errors due to stress. Only 4 out of 18 teams gave the correct dose. In a real clinical scenario it may also take more than 3 min for multiple intubation attempts, after the first failed attempt at intubation, before a decision is made to use sugammadex. Therefore, we think that real patients might have had a much worse outcome had we not used a manikin! We do not agree with the statement of Mirakhur et al. that sugammadex can be administered to a patient within 3 min during normal clinical work. Of course, in an experimental setting without tough clinical decision-making, high-dose rocuronium may be reversed immediately. We would also stress that other medication is administered to patients for induction of anaesthesia and intubation. There is no universal technique that is accepted for rapid sequence induction. These medications can certainly suppress spontaneous breathing. There may be the need for acute opioid reversal with naloxone and there may also still be a depressant effect of the induction agents that cannot be reversed. Of course, early return of diaphragmatic movement may be important in some patients, but from the literature available at the time of our study it takes an average of 2.2 min to reach a TOF ratio of 0.9, which is internationally recognised as the safe ratio to extubate a patient's trachea and without the risk of recurarisation. All our randomly selected participants in the study were well instructed in the use and working mechanism of sugammadex in the months before the study. We clearly demonstrated that human factors play a very important role during crisis situations. Medical personnel may indeed need protocols or clearly written package inserts to prevent them from making mistakes in these stressful situations. This finding is certainly not new, investigations into aviation and medical disasters have clearly shown this in the past. Finally, we think a simplified dose regimen as proposed by Mirakhur and colleagues is an excellent idea and would improve patient safety. No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com.