Access methods in nutritional support.

The limiting factor in nutritional support of the vast majority of patients is the attainment and maintenance of safe access, whether it be to the venous system for total parenteral nutrition (TPN) or to the gut for enteral nutrition. Indeed, the mainstay of nutritional support therapy is deciding the appropriate route for nutritional support and obtaining access to provide that support. Central to this decision is the concept of ‘intestinal failure’ which was defined by Fleming & Remington (1981) as ‘a functioning gut mass below the minimum necessary for the adequate digestion and absorption of nutrients’. Intestinal failure is the only absolute indication for TPN and should not be confused with difficulties in intestinal access. It is still a common occurrence to find a patient on TPN in whom application of the modern principles of intestinal access would allow enteral feeding.