How to choose the route.

Choosing the route for nutrition support delivery is one of the main steps in the algorithm of providing successful nutrition to the critically ill, but it is certainly not an easy process. The rationale should be guided not only by principles like physiology and benefit versus harm, but also by individual patient factors like feasibility, contraindications, predicted versus actual tolerance, and (most important) the timing for starting food delivery. Although oral nutrition is the more physiological route for feeding, it is seldom possible or sufficient in critically ill patients. Enteral nutrition, in the form of tube feeding, remains the best option in the absence of absolute contraindications, but many other factors should be taken into account. These include the importance of starting early and trying to achieve target nutrients delivery early, especially in previously undernourished or in most severely ill patients, as well as the gastrointestinal intolerance present in the majority of critically ill patients. Parenteral nutrition is an alternative route for nutrition delivery when the enteral one is impossible or insufficient. The most common complication when choosing this route is overfeeding, which has been associated with increased complications rate. On the other hand, the most common complication of enteral nutrition is underfeeding, which has also been associated with worse outcome and even increased mortality. Combining enteral with supplemental parenteral nutrition is therefore a rational approach for providing early and adequate nutritional support in the most severely ill patients.