Authors:
- Dr Sofia Costas, Queen Elizabeth University Hospital, Glasgow
- Dr Eric Makmur, Queen Elizabeth University Hospital, Glasgow
- Dr Yin Yin Lim, Cardiff and Vale University Health Board
- Professor Alan Macfarlane, Glasgow Royal Infirmary and Honorary Professor at the University of Glasgow
NAP8 is due to launch in early 2026 and will focus on complications of not just regional anaesthesia but also peripheral nerve or spinal cord injuries following general anaesthesia, monitored anaesthesia care, or sedation.
The National Audit Projects (NAPs) are internationally recognised as important reports with potentially significant impact on anaesthetic practice and patient outcomes. Each NAP is coordinated by the RCoA Centre for Research and Improvement (CR&I) and focuses on rare complications of anaesthesia. The topic selected must be important to patients and anaesthetists and be incompletely studied in incidence or nature.
Why this topic?
The consequences of nerve injury can be potentially devastating, irrespective of whether it is secondary to a regional technique (such as a popliteal block in the patient's story below), positioning, compression, or any other mechanism.
‘When I woke up from my operation, I had no pain at all… but after two days, I still couldn't feel my leg below the knee’
Days later
By day three, I had a slight feeling of pins and needles, but I still couldn’t move my toes. Four days after discharge, I woke up with the feeling that my leg had swollen in my cast, as it felt so tight and uncomfortable, and my toes were beginning to go a funny purple colour. Removing the cast made no difference.
Weeks later
I was sent to the pain management team to help with the numbness and the pins and needles in my leg. But unfortunately, pain medication did not work very well for me, and I was finding I had to up the pain medication.
Months later
The nerve test was extremely painful, as even though my leg is numb, it is extremely sensitive to touch. This showed damage below the knee, but could not tell me if or when the feeling in my leg would come back. Meantime, it took about a year to be able to get a wheelchair to suit my needs and help me get around with my children.
Years later
I still have a numb leg to this day – it is the feeling of like you've been sat on your leg underneath you for too long; it's that numbness you get just before the pins and needles kick in, and the pins and needles I get is the pain that you get when you put your foot down that shoots up your leg. I have learned to cope without medication, as I feel that if I take the medication, it takes the pain away, but then I need more medication to get over the pain the next day. For me, having young children, this is not an option, so unfortunately, l'm still in the wheelchair.
Unlike NAP3, which focused solely on central neuraxial blocks, NAP8 will examine complications of both central neuraxial and peripheral nerve blocks. Despite the growing popularity of regional anaesthesia, there remains a lack of robust data for many complications following peripheral nerve blocks, particularly nerve injury. Furthermore, regional anaesthesia is the most common reason for anaesthesia-related litigation, with claims relating to peripheral nerve blocks in particular doubling between 2008 and 2018. It is therefore vital to provide patients and anaesthetists with accurate information about the incidence of nerve damage and other rare complications of peripheral nerve blocks. This, in turn, will facilitate shared decision-making during the consent process.
It has been almost two decades since NAP3 took place. The surgical population has become older, frailer and more comorbid, with a higher average body mass index. New pharmacological agents, such as direct oral anticoagulant drugs, have further altered the risk profile for central neuraxial blocks. There is a need to close the audit loop to provide accurate, contemporary data in people undergoing general surgical, obstetric, paediatric, and pain procedures.
Work done so far
The RCoA CR&I NAP8 team have been working together on logistics since October, including the assembling of the steering group, which has been meeting monthly since January. The inclusion of other peripheral nerve and cord injuries sustained under general anaesthesia unrelated to either regional anaesthesia or the surgery itself means the scope of NAP8 will be a challenge, and much of the steering group's discussions so far have been focused on this issue. The three NAP8 fellows formally begin their tenure in August 2025, and we also have an Irish fellow since NAP8 will include Ireland via the College of Anaesthesiologists of Ireland (CAI). The regulatory processes are being navigated in both the UK and Ireland, and we will soon commence building the baseline surveys, activity survey, and the case-registry database. Extremely useful meetings have also taken place with representatives from the Independent Healthcare Providers Network and the Private Healthcare Information Network, which we hope will lead to improved independent sector engagement in this NAP.
What next?
More than 300,000 peripheral nerve blocks were recorded in NAP7, and coupled with the involvement of the CAI and hopefully an increased number of independent sector patients, the NAP8 peripheral nerve block dataset will be the biggest, most detailed, and largest in the world to date. Examining central neuraxial complications means that NAP8 will be the first NAP to re-audit a previous NAP. The inclusion of peripheral nerve and spinal cord injury sustained under general anaesthesia, sedation or monitored anaesthesia care will provide an opportunity to study these complications in an era of modern surgical techniques and procedures, many of which did not exist when the original publications were produced.
However, as with all NAPs, all of this will only be possible, with the support, diligence and enthusiasm of not just local coordinators but of every single anaesthetist who helps with both entering survey data and remaining vigilant for any of the complications that occur during the registry phase.
Every NAP comes with challenges. In addition to the scale of the project, we predict that some specific to NAP8 will be how best to capture complications such as peripheral nerve injuries that do not present immediately but instead often post-discharge. Determining the causation of such injuries may also be difficult in some cases, given the nature of how NAPs function. We will also need to follow up patients long enough to acquire meaningful data about symptom resolution. Rather than being nervous, however, we are excited about the challenge and have a plan. We sincerely hope that, with the help again of all UK (and Irish) anaesthetists, we can deliver yet another seminal NAP – one that will improve patient consent, follow-up, and management of both regional anaesthesia complications and perioperative nerve injury, while ultimately enhancing evidence-based anaesthesia practice.
If you are interested in becoming a local coordinator, then we would be delighted to hear from you via email (nap@rcoa.ac.uk). Pending approvals, our hope is to launch the baseline surveys towards the end of 2025 with a view to starting the case-registry phase in early 2026. The activity survey will, as before, run in the middle of the case-registry phase.
Thank you: we're grateful to the patient who shared their story in this article and to Regional Anaesthesia – UK, the European Society of Regional Anaesthesia, the Obstetric Anaesthetists’ Association, the Association of Anaesthetists, the Association of Paediatric Anaesthetists of Great Britain and Ireland, and the College of Anaesthesiologists of Ireland for financial support with NAP8.