“The use of nicotine, alcohol, and illicit substances, alone or in combination, may predispose patients with burn injuries to poor outcomes and complications in a hospital setting,” explains Kevin M. Klifto, PharmD. “Current literature reports that up to 50% of the burn population dying from burn-related injuries are intoxicated. However, there exist no guidelines based on clinical evidence of these intoxicants following burn-related injuries.”

For a paper published in Burns, Dr. Klifto, C. Scott Hultman, MD, MBA, FACS, and colleagues conducted a systematic review and meta-analysis to compare outcomes and complications of patients with burns who were admitted to the hospital with the intoxication of nicotine, alcohol, illicit substances, or any combination of these with those of patients with burns who were free of intoxicants. “We aimed to compile information in order to create a uniform set of data for clinical interpretation for different populations, with the goal of improving patient outcomes,” says Dr. Klifto. “Based on peer-reviewed literature, we hypothesized that patients with burn injuries who were under the influence of these intoxicants upon hospital admission would have poorer outcomes and more complications than those admitted without the use of intoxicants.” The researchers searched four databases to identify 6,385 studies that included 26,512 patients admitted to the hospital with substance use and 299,543 admitted without these characteristics.

Substance Use Linked With Worse Outcomes in Patients With Burns

The researchers observed that nicotine/smoking, alcohol, and/or illicit substance use was associated with more burn-related operations, higher rates of graft loss/failure, longer hospital length of stay (LOS), higher rates of intubation, longer intensive care unit (ICU) LOS, increased mortality, and increased wound/local skin infections when compared with no substance use. “Specifically, nicotine/smoking was associated with higher rates of intubation and wound/local skin infections,” Dr. Klifto adds. “Alcohol was linked with more days spent on a ventilator, higher rates of intubation, higher rates of inhalation injury, longer ICU LOS, and increased mortality when compared with no alcohol use. Illicit substance use was associated with a higher percentage of total body surface area (%TBSA) burns, longer hospital LOS, higher rates of intubation, higher rates of inhalation injury, longer ICU LOS, and increased wound/local skin infections when compared with no illicit substance use.”

One of the biggest takeaways from this study and others pertaining to burn-related injuries is the lack of data, Dr. Klifto explains. “Burn research is a huge area of opportunity for future researchers,” he says. “Seeing how limited the current literature is on this topic is eye-opening, especially since healthcare providers regularly refer to the literature in order to make clinical recommendations (Table).”

Variation in Patient Scenarios & Outcomes

The study team hopes their findings will help guide physicians to improve outcomes for patients with burn injuries who may be under the influence of one or more of the studied intoxicants. “The systemic effects of nicotine/smoking, alcohol, and illicit substances can complicate clinical scenarios,” adds Dr. Hultman, MD, MBA, FACS. “However, findings should not be applied to all patients without proper clinical context and judgment. Variations in patient scenarios may potentially impact outcomes, which necessitates additional research.”

Drs. Clifton and Hultman note the need for future research focused on the direct causality of nicotine, alcohol, and illicit substance use on patient outcomes. “Prospective studies are limited in the burn population; only one study included in our review was a prospective study,” says Dr, Clifton. “Also, our research reviewed illicit substances from a general perspective; studying specific illicit substances—such as heroin, cocaine, benzodiazepines, lysergic acid diethylamide, amphetamines, and phencyclidine—will provide greater insight on the individual impacts on patient outcomes.” Dr. Klifto adds that outcomes and complications with no identifiable information in the literature included reports of amputations, nosocomial infections, decubitus ulcers, renal failure, and ventilator-associated events. “Studying substance use in patients with burns in conjunction with any of these conditions would add new information,” he says.