A 67-year-old man with a medical history of coronary artery disease, hypertension, and cirrhosis presented to the emergency department reporting 5 days of cough, fever, anorexia, and malaise. He was found to be tachycardic, hypotensive, in severe respiratory distress, and oliguric, and he had peripheral cyanosis and a lactate level of 3.1 mmol/L (reference range, 0.6-1.7 mmol/L) (27.9 mg/dL; reference range, 5.0-15 mg/dL). He was intubated, given empirical antibiotics for suspected community-acquired pneumonia, resuscitated with 3 L of Ringer lactate solution, and admitted to the intensive care unit. Following admission, the patient’s lactate level decreased to 1.2 mmol/L (10.8 mg/dL). However, blood pressure declined progressively through the night despite further fluid resuscitation and the addition of vasopressors (norepinephrine, vasopressin, and epinephrine) and hydrocortisone. The following morning, his central venous pressure was 13, stroke volume variation was 7%, and lactate was 3.0 mmol/L (27.0 mg/dL). Mean arterial pressure of 60 to 65 mm Hg was achieved but lactate continued to increase to 4.2 mmol/L (37.8 mg/dL).