Post-Operative Dietary Advice - Ward Round Guide

The Core Principle: ERAS (Enhanced Recovery After Surgery)

"Early resumption of oral nutrition is an indispensable component for enhanced recovery." - Current Surgical Therapy 14e

Phase-by-Phase Diet Progression

Phase 1 - Immediate Post-Op (Day 0 to Day 1)

• Water, ice chips
• Clear broth / consomme
• Apple juice, clear grape juice
• Jelly (Jell-O), popsicles
• Black tea or black coffee
• Sports drinks (e.g., Lucozade)

Phase 2 - Full Liquids (Day 1-2)

• Milk, milkshakes
• Yoghurt (smooth)
• Cream soups / blended soups
• Protein shakes / nutritional supplements (e.g., Ensure, Fortisip)
• Custard, ice cream
• Mashed potato (thin/wet consistency)

Phase 3 - Soft Diet (Day 2-5, depending on surgery)

• Scrambled eggs, soft-boiled eggs
• Soft fish, minced or ground meat
• Well-cooked vegetables (soft, not raw)
• Bananas, canned/stewed fruit
• Porridge / congee / soft rice
• Soft bread without crusts
• Pasta (well-cooked)
• Cottage cheese

Phase 4 - Normal Diet (Week 1-2 onwards)

• Gradual return to normal as tolerated
• Focus on high protein and nutrient-dense foods

What Nutrients Matter Most Post-Op?

Surgery-Specific Advice

GI / Abdominal Surgery (Bowel, Colon, Stomach)

• Strictest progression - wait for return of flatus before advancing beyond liquids
• Avoid high-fibre foods until bowel function fully restored
• After bowel resection: small, frequent meals (6x/day) instead of 3 large ones
• After gastrectomy: "dumping syndrome" risk - avoid sugary foods and large meals, lie down after eating

Laparoscopic Surgery (Appendicectomy, Cholecystectomy, Hernia)

• Can often tolerate soft diet within 24-48 hours
• After cholecystectomy: low-fat diet initially (no bile reservoir, so fat absorption is slower) - avoid fatty/fried foods for 2-4 weeks

Cardiac/Thoracic Surgery

• Heart-healthy diet: low sodium, low saturated fat
• High protein for sternal wound healing
• Fluid restriction if heart failure is a concern

Orthopaedic Surgery (Hip/Knee Replacement, ORIF)

• Can eat normally quite quickly - often day of or day after surgery
• High protein + calcium + Vitamin D for bone healing
• Constipation is common (opioids + immobility) - encourage fluids and fibre

Head & Neck / ENT Surgery

• May need nasogastric tube or modified textures (soft, pureed)
• Dysphagia assessment (SALT team) may be needed after throat/tongue/jaw surgery

What to Tell Patients to AVOID Post-Op

Red Flags - When to Escalate or Stop Feeding

• Nausea/vomiting - step back to previous phase
• Abdominal distension with absent bowel sounds - possible ileus - stop oral intake, inform surgical team
• Anastomotic leak signs (fever, tachycardia, abdominal pain after GI surgery) - NPO immediately
• Dysphagia or aspiration - stop oral feeding, get SALT review
• Refeeding syndrome (in severely malnourished patients restarted on feeds) - monitor phosphate, magnesium, potassium

Practical Phrases to Use on Ward Round

• "Start with clear fluids today - sips of water and broth. If that's well tolerated and you pass wind, we'll move to soups and yoghurt tomorrow."
• "Eat little and often - 5-6 small meals are better than 3 big ones right now."
• "Your body needs protein to heal your wound - eggs, fish, chicken, dairy are all good."
• "Avoid alcohol and heavy fried foods for at least 2 weeks."
• "If you feel sick or your tummy bloats, slow down and let the nurse know."

Quick Reference Summary Card

DAY 0-1:    CLEAR FLUIDS (water, broth, jelly)
DAY 1-2:    FULL LIQUIDS (soups, yoghurt, shakes)
DAY 2-5:    SOFT DIET (eggs, fish, soft veg)
WEEK 1-2+:  NORMAL DIET (high protein, avoid alcohol/fatty/spicy)

Post-Op Diet Advice - Surgical Ward Round

Laparoscopic Patients (Your Main Group)

The Simple Rule to Tell Every Lap Patient:

"If you're not feeling sick and you've passed wind - you can eat."

Timeline for Lap Patients

Common Lap Operations & Specific Tips

Lap Cholecystectomy (most common)

• Progress to normal diet within 24-48 hours usually
• Low fat for 2-4 weeks - no bile reservoir, fat absorption is slower
• Avoid: fried food, fatty meats, cream, full-fat dairy initially
• They can eat: lean meat, fish, eggs, vegetables, fruit, rice, bread
• Tell them: "Your gallbladder stored bile to digest fat. Without it, your liver still makes bile but drips it slowly - so fatty food may cause loose stools or cramps for a few weeks."

Lap Appendicectomy

• Diet advances fastest of all - often normal by Day 1-2
• No specific dietary restrictions after
• If there was perforation/peritonitis - slower progression, treat like open

Lap Hernia Repair (inguinal/ventral)

• Normal diet within 24-48 hours
• High fibre and fluids to avoid straining/constipation - very important to protect the repair
• Tell them: "Don't strain on the toilet - eat plenty of vegetables, fruit, and drink 2 litres of water a day"

Lap Bowel / Colorectal Surgery

• Slower than other lap ops - wait for flatus before advancing
• Day 0-1: Clear fluids only
• Day 1-2: Full liquids
• Day 2-3: Soft diet
• Small frequent meals (6x/day) ongoing for first 2-4 weeks

Open Patients (Your 1-2 Cases)

• Wait for return of bowel sounds + passing flatus before advancing past liquids
• Typical timeline is 1-2 days behind the lap equivalent
• Abdominal distension = stop and reassess
• High protein is even more important - larger wound to heal

What ALL Post-Op Patients Should Eat More Of

• Protein (chicken, fish, eggs, dairy) - wound healing, prevents muscle wasting
• Vitamin C (orange, kiwi, peppers) - collagen for wound healing
• Fluids - minimum 1.5-2 litres/day unless restricted
• Iron-rich food if had significant blood loss (red meat, lentils, fortified cereals)

What ALL Post-Op Patients Should Avoid

Constipation Warning (Very Common Post-Op)

• Drink plenty of water
• Eat fruit, vegetables, wholegrain bread once tolerating
• Laxatives are routinely prescribed - take them, don't wait until you're uncomfortable

One-Liner Scripts for the Bedside

• "Start with fluids, move to soups and yoghurt, then back to normal - usually within 2-3 days for lap."
• "Eat little and often for the first week."
• "Your wound needs protein to heal - eggs, chicken, fish, dairy."
• "Avoid alcohol, fried food and large meals for now."
• "If your tummy feels bloated or you're vomiting - slow down and tell the nurse."

Quick Pocket Card

LAP PATIENT DIET:
Day 0 eve:  Sips water / clear fluids
Day 1:      Soups, yoghurt, shakes
Day 2:      Soft food (eggs, fish, porridge)
Day 3+:     Normal - avoid fat/spice/alcohol

OPEN PATIENT: Add 1-2 days to above, wait for flatus

ALL PATIENTS: High protein + fluids + avoid constipation

Antipyretics for Post-Op Fever

First Line - Paracetamol (Acetaminophen)

• Safest option post-op
• Works for pain AND fever simultaneously
• Use IV route if patient still NBM or vomiting

Second Line - NSAIDs (Ibuprofen / Diclofenac)

• Avoid if renal impairment or dehydrated
• Avoid after bowel anastomosis (increased leak risk)
• Avoid if GI bleed risk or peptic ulcer history
• Avoid in cardiac patients

The "5 Ws" of Post-Op Fever - Treat the CAUSE

If Fever > 38.5°C with Rigors / Haemodynamic Compromise

1. Sepsis 6 within 1 hour:
   • Blood cultures x2
   • Urine culture
   • FBC, CRP, lactate, U&E
   • IV fluids
   • Broad-spectrum IV antibiotics (e.g., Co-amoxiclav / Piperacillin-Tazobactam / Cefuroxime depending on source)
   • Oxygen if saturations low

Quick Summary

TEMP > 37.5°C:
  → Paracetamol 1g IV/oral (first always)
  → Find the CAUSE (5 Ws)
  
TEMP > 38.5°C + unwell:
  → Paracetamol + sepsis screen + cultures
  → IV antibiotics if sepsis suspected
  
NSAIDs: second line, use with caution post-op

Remember: Paracetamol is your workhorse. Don't reach for antibiotics without a source - but don't delay them if the patient looks sick.

Lap Patient with Port Site Pain

First - Assess the Pain

Pain Management - Stepwise (WHO Ladder)

Step 1 - Regular Paracetamol (Always First)

• Paracetamol 1g oral/IV every 6 hours (regular, not PRN)
• Do this for ALL lap patients routinely
• Covers mild-moderate port site pain well

Step 2 - Add an NSAID

Paracetamol + NSAID together = better than either alone

Step 3 - Weak Opioid (Moderate Pain)

Step 4 - Strong Opioid (Severe Pain - not typical for lap)

If lap patient needs morphine for port site pain on Day 2+ - reassess, something may be wrong

Local Measures

• Local anaesthetic infiltration - surgeons often inject bupivacaine at port sites intraoperatively (ask if done)
• Ice pack on port sites - simple but effective for 24-48 hrs
• Position of comfort - semi-recumbent often helps

Shoulder Tip Pain (Very Common Post-Lap)

• Reassure the patient: "This is normal and will settle in 24-48 hours"
• Sit upright or knee-chest position helps gas disperse
• Regular paracetamol + time
• No specific drug needed, NSAIDs help

Red Flags - When Port Site Pain is NOT Normal

Quick Prescribing Summary

MILD PORT SITE PAIN:
→ Paracetamol 1g every 6 hrs (regular)
→ + Ibuprofen 400mg every 8 hrs with food

MODERATE PAIN:
→ Paracetamol + NSAID + Tramadol 50-100mg PRN

SEVERE PAIN (unusual for lap):
→ Reassess first
→ Morphine 2.5-5mg PRN + surgical review

SHOULDER TIP PAIN:
→ Reassure + sit upright + paracetamol

ALL OPIOIDS: co-prescribe laxative

Dynapar (Diclofenac Sodium)

Available Forms in India

How to Use in Post-Op Lap Patient

IM Injection (Most Common in Wards)

• Dynapar AQ 75mg IM once or twice daily
• Give deep IM into gluteus / upper outer quadrant
• Maximum 150mg/day
• Short course only - 2-3 days post-op

Oral (Once Tolerating Diet)

• Diclofenac 50mg oral twice or three times daily with food
• Switch from IM to oral as soon as patient eating

Use in Post-Op - Is It Safe?

YES, good choice for lap patients because:

• Strong anti-inflammatory - reduces port site inflammation
• Analgesic + antipyretic combined
• Works well with paracetamol (different mechanism)
• Reduces opioid requirement

CAUTION / AVOID in:

Combine With Paracetamol for Best Effect

STANDARD POST-OP LAP REGIMEN:

Paracetamol 1g IV/oral  →  every 6 hours (regular)
      +
Dynapar AQ 75mg IM      →  every 12 hours (regular, 2-3 days)
      +
Tramadol 50mg IV/oral   →  PRN (rescue, if above not enough)

Always co-prescribe:
→ PPI (Pan 40 / Omeprazole 20mg) to protect stomach
→ Laxative if on tramadol/opioids

Important - Always Co-Prescribe a PPI

• Pantoprazole 40mg (Pan 40) oral/IV once daily
• Omeprazole 20mg oral once daily
• Give routinely with every NSAID prescription post-op

Quick Summary

Dynapar = Diclofenac Sodium (NSAID)

Post-op use:
→ 75mg IM every 12 hrs (Dynapar AQ)
→ Max 2-3 days IM, then switch to oral
→ Always with Paracetamol + PPI
→ Check renal function before use
→ AVOID if anastomosis / dehydrated / renal impairment

Dynapar IV - Yes, It Can Be Given IV

Dynapar AQ - IV Route

How to Give IV - Step by Step

Dynapar AQ 75mg (3mL ampoule)
→ Draw up 3mL
→ Can dilute in 100mL Normal Saline
   and give over 15-30 min (preferred - less irritation)
→ OR slow IV bolus over 2-3 minutes
→ Do NOT give as rapid IV push

Diluted infusion over 15-30 min is preferred - reduces vascular irritation and side effects

IV vs IM - Which to Choose?

Onset of Action

Important Cautions for IV Use

• Check renal function before giving - diclofenac is nephrotoxic especially if dehydrated post-op
• Always co-prescribe PPI - Pantoprazole 40mg IV/oral
• Avoid in anastomotic bowel surgery - leak risk
• Do not mix with other drugs in same syringe
• Watch for hypotension - rare but can occur with rapid IV

Practical Ward Regimen

Post-op Lap Patient (pain at port site):

1. Paracetamol 1g IV every 6 hrs  ← regular
2. Dynapar AQ 75mg IV every 12 hrs ← regular (dilute in 100mL NS, give over 20 min)
3. Tramadol 50mg IV PRN every 8 hrs ← rescue
4. Pan 40 (Pantoprazole) 40mg IV OD ← always with NSAID

Right-Sided Chest Pain - Post-Op Surgical Patient

STOP - Think Dangerous First

Immediate Bedside Assessment

Do This NOW:

1. VITALS - RR, HR, BP, SpO2, Temp
2. Look - distress? sweating? cyanosis?
3. Auscultate chest - equal air entry? crackles? absent sounds?
4. Percuss chest - dull = effusion/consolidation, hyper-resonant = pneumothorax
5. Check legs - swollen/red calf? = DVT → PE
6. Check wound/abdomen - tenderness, guarding?
7. Ask - sudden or gradual? worse on inspiration? SOB?

Key Differentiator - SpO2

Most Likely Causes by Day Post-Op

Investigations to Order

Bedside / Immediate

• SpO2 + ABG if SpO2 low
• ECG - sinus tachycardia / S1Q3T3 pattern in PE
• CXR - pneumothorax, consolidation, effusion, raised hemidiaphragm

Bloods

• D-Dimer - if PE suspected (high sensitivity, low specificity)
• FBC - raised WCC = infection
• CRP - infection/inflammation
• LFTs - if post-cholecystectomy (bile leak?)
• Troponin - if cardiac chest pain not excluded

If PE Suspected

• Wells Score first
• CTPA (CT Pulmonary Angiogram) - gold standard for PE
• V/Q scan - if contrast contraindicated (renal impairment)

Wells Score for PE - Quick Bedside

Post-op surgical patient already scores +1.5 just for recent surgery

Management by Likely Cause

If PE Suspected (SpO2 drop + tachycardia)

→ O2 immediately (target SpO2 >94%)
→ IV access + bloods (D-dimer, FBC, troponin, ABG)
→ ECG + CXR
→ CTPA urgently
→ If high clinical suspicion → start LMWH (Clexane/Enoxaparin)
   BEFORE scan result (don't delay treatment)
→ Inform senior / consultant immediately

If Atelectasis (Day 1-2, mild desaturation, fever)

→ O2 via face mask
→ Sit patient upright
→ Incentive spirometry / deep breathing exercises
→ Physiotherapy - chest percussion, ambulation
→ Adequate analgesia (pain → splinting → atelectasis)
→ CXR to confirm

If Pneumonia (fever, cough, crackles, consolidation on CXR)

→ CXR + sputum culture
→ Antibiotics: Co-amoxiclav / Augmentin OR
              Ceftriaxone + Azithromycin
→ O2, physio, fluids

If Diaphragmatic/Referred Pain (post-lap, normal SpO2, shoulder tip)

→ Reassure patient
→ Regular paracetamol + Dynapar AQ
→ Encourage ambulation
→ Sit upright - helps CO₂ disperse
→ Should resolve 24-48 hrs

Do NOT Miss

⚠️  POST-OP RIGHT CHEST PAIN + ANY OF THESE = EMERGENCY:

→ SpO2 dropping
→ HR > 100
→ RR > 20
→ BP dropping
→ Patient looks unwell / distressed
→ Absent breath sounds one side

= Call senior IMMEDIATELY, get CTPA, start O2 + LMWH

Quick Summary

RIGHT CHEST PAIN POST-OP:

STEP 1: Vitals + SpO2 + auscultate
STEP 2: ECG + CXR (do immediately)
STEP 3: Bloods - D-dimer, FBC, CRP, ABG

NORMAL SpO2, mild symptoms → likely atelectasis or referred pain
LOW SpO2 + tachycardia → PE until proven otherwise → CTPA + LMWH

NEVER dismiss post-op chest pain without examination + CXR minimum