The Surviving Sepsis Guidelines provide a suitableframework to guide therapy for the majority of patientswith septic shock . Appropriate and timely antimicro-bial therapy, source control if indicated, fluid therapy,and targeted vasopressors remain the backbone of treat-ment. However, a small proportion of patients fail to re-spond to these measures and deteriorate precipitouslyinto refractory shock and progressive multi-organ fail-ure. This subgroup of patients is often poorly repre-sented in large randomised controlled trials investigatingthe efficacy of interventions in septic shock. As a result,there is little conclusive evidence to guide managementin this particular population.