There is a relatively strong rationale for considering the use of steroids in patients with refractory septic shock. Relative adrenal insufficiency is common in patients with refractory septic shock (50-75% of patients) [39] . In addition to such relative adrenal insufficiency and the blunted response to corticotrophin, a large body of evidence indicates that sepsis and refractory septic shock are characterized by peripheral tissue resistance to corticosteroids [40, 41] . In septic patients, this can be evidenced in a variety of ways. First, global cortisol binding, which carries cortisol from the adrenal glands to the tissues, decreases in patients with severe sepsis [42] . Second, the number and binding affinity of glucocorticosteroid receptors may be reduced in patients with sepsis and severe sepsis [43] , leading to a decrease in the conversion of cortisone to its active form, cortisol, particularly by IL-2 levels in the tissues. Finally, data have been published demonstrating that moderate doses of steroids may restore cell sensitivity to vasopressors [44] . This may reduce the intensity of the inflammatory response and decrease organ dysfunction. Low-dose steroid treatment is also well tolerated [40] .