Original Article Ewha Med J 2012;35(2):83-88 pissn 2234-3180 / eissn 2234-2591 제왕절개술을위한척추마취시국소마취제주입속도가저혈압에미치는영향 강용인ㆍ방은치ㆍ신동욱ㆍ권대은ㆍ김수연ㆍ이현숙ㆍ조경숙ㆍ이수연 차의과학대학교강남차병원마취통증의학교실 Effect of Injection Speed of Local Anesthetic on Hypotension during Spinal Anesthesia for Cesarean Section Yong In Kang, Eun Chi Bang, Dong-Wook Shin, Dae Eun Kweon, Su Yeon Kim, Hyun Sook Lee, Kyung Sook Cho, Su Yeon Lee Department of Anesthesia and Pain Medicine, Gangnam Medical Center, CHA University, Seoul, Korea Objectives: Maternal hypotension is a common problem during cesarean section under spinal anesthesia. We evaluated the influence of injection speed of local anesthetic to subarachnoid space on maternal hypotension and level of sensory block. Methods: Bupivacaine (0.5%) 9 mg with fentanyl 10 μg was injected to subarachnoid space either quickly (during 20 seconds, 0.1 ml/sec, n=20) or slowly (during 100 seconds, 0.02 ml/sec, n=20) in parturients scheduled for elective cesarean section. The onset and level of sensory block was checked and heart rate and blood pressure was checked by 2.5 minutes during 20 minutes. Hypotension (systolic blood pressure <100 mmhg or <70% of baseline) was treated with ephedrine. Results: Hypotension occurred 70% of parturients with spinal anesthesia. Slow injection didn t influence on the onset and level of sensory block and didn t reduce the incidence of hypotension. But onset of hypotension was delayed. Conclusion: Slow injection (during 100 seconds, 0.02 ml/sec) of local anesthetic delayed onset of hypotension and required less amount of ephedrine. Slow injection of local anesthetic was one of the effective methods for the cardiovascular stability during cesarean section under spinal anesthesia. (Ewha Med J 2012;35(2):83-88) Key Words: Anesthesia; Cesarean section; Hypotension; Speed; Spinal injection 서론 제왕절개술마취를시행하는데있어서척추마취는경막외마취에비해시술과정이간단하면서발현시 Received: June 5, 2012, Accepted: July 2, 2012 Corresponding author: Yong In Kang, Department of Anesthesia and Pain Medicine, Gangnam Medical Center, CHA University, 566 Nonhyeon-ro, Gangnam-gu, Seoul 135-913, Korea Tel: 82-2-3468-3080, Fax: 82-2-558-1119 E-mail: anein09@hanmail.net 간이짧으며, 적은용량의국소마취제로원하는부위의마취를할수있어전신적독성이적고신경차단효과가우수한장점이있다 [1]. 반면마취시간이한정되어있으며개인차이에따른마취차단높이조절이어렵고특히, 저혈압발생률이 68 92% 로높은단점이있다 [2]. 산모에게척추마취를시행하게되면차단부위의교감신경차단으로인해혈관이확장되고앙와위저혈압증후군때문에저혈압이심해지며오심, 구토, 불안정한심혈관계반응으로저혈압, 빈맥, 서맥, 부정맥등 83
Ewha Med J Vol. 35, No. 2, 2012 이발생한다. 저혈압발생시에는자궁혈류감소로인해태아에게는산증과저산소증, 서맥이올수있으므로 [3,4] 혈압상승제를이용한즉각적교정이필요하며저혈압의발생빈도를감소시키기위해수액주입과앙와위저혈압증후군예방을위한우측둔부쐐기앙와위자세를취하고예방적으로 ephedrine을투여하기도한다. 척추마취시발생하는저혈압발생은마취차단높이와연관이있으며차단높이는환자의나이, 신장, 국소마취제의비중과용량, 척추천자부위와바늘방향, 국소마취제주입후의자세, 복압등이영향을미치며환자체중, 국소마취제의주입속도, 혈관수축제혼합여부, 기침은영향을미치지않는다 [5]. Bucx 등 [6] 과 Stienstra 등 [7] 은지주막하강으로의국소마취제주입속도와마취차단높이, 저혈압발생에대한반복연구에서연관성이없다고보고하였지만, 저자들은임상적으로산모에게척추마취를시행하면서국소마취제의주입속도와혈압하강정도가연관이있는경험을하였기에본연구를시행하였다. 따라서본연구에서는산모에게척추마취시국소마취제주입속도가저혈압발생빈도및혈압하강정도, 마취차단높이에영향을미치는지알아보고주입속도가느린경우저혈압을감소시킬수있는지를알아보았다. 방법 선택적제왕절개술이예정된미국마취과학회신체등급분류 1 2에해당하는산모를대상으로본연구를시행하였으며쌍태아, 전치태반, 임신중독성고혈압이있는산모는연구에서제외시켰다. 제왕절개술을통해분만을원하는산모에게척추천자후지주막하강으로 0.5% bupivacaine 9 mg과 fentanyl 10 μg을 0.1 ml/sec 속도로 20초간주입하는군 (group F) 20명과 0.02 ml/sec 속도로 100초간주입하는군 (group S) 20 명을무작위로선택하였다. 산모가수술실입실후하트만용액을정맥으로빠른속도로정주하면서산모의심박수, 수축기혈압, 이완기혈압, 맥박산소포화도를측정하였다. 산모를좌측위로한뒤요추 3 4 간에 26 G Whitacre 바늘사면을위로하여천자하였다. 뇌척수액의유출을확인한후지주막하강으로 0.5% bupivacaine 9 mg과 fentanyl 10 μg을 20초간, 100초간주입하였다. 약물주입후환자를앙와위로하고우측둔부에쐐기를넣어앙와위저혈압증후군을예방하였다. 지주막하강으로국소마취제주입완료후부터지 속적으로알코올솜을사용하여마취차단높이와마취시작시간을기록하였다. 척추마취후심전도와자동혈압기, 맥박산소계측기를이용하여 2.5분간격으로 20분동안심박수, 수축기혈압, 이완기혈압, 맥박산소포화도를측정하였고, 기준치수축기혈압이 100 mmhg 이하로내려가거나 30% 이상감소시 ephedrine 8 mg을정주하였으며수축기혈압이 100 mmhg 이상, 처음수축기혈압의 70% 이상될때까지반복정주하였고 ephedrine에반응이없는경우 phenylephrine을 20 μg을정주하였다. Ephedrine이처음사용된시간과총투여량을기록하였다. 척추마취후수술시작시간과태아분만시간, 태아 Apgar 1분, 5분점수를기록하였고 20분간산모에게주입된수액의양을측정하였다. 산모에게오심, 구토증상이있는지여부를기록하였다. 모든측정치는평균 ± 표준편차로표시하였다. 통계는 SPSS version 20.0 (SPSS Inc., Chicago, IL, USA) 을이용하였으며두군간의심박수, 수축기혈압, 이완기혈압, 척추마취차단높이, 마취가시작된시간, 수술시작시간, 태아분만시간과체중, Apgar 점수, 수액총투여량, ephedrine 총사용량, 처음투여시간은 independent t test로검증하였고두군간의 ephedrine 사용건수, 오심증상건수는 Pearson chi-square test 를이용하여분석하였다. P값이 0.05 미만인것을통계학적으로의미가있는것으로보았다. 결과 제왕절개술을시행받기위해척추마취를시행받을때국소마취제의주입속도가 0.1 ml/sec로빠른군 (group F) 와 0.02 ml/sec로느린군 (group S) 간에산모나이, 신장, 체중, 임신주수는차이가없었다 (Table 1). 수술시작시간, 태아분만시간, 태아 1분, 5분 Apgar 점수, 태아체중, 20분간투여된수액양도두 Table 1. Patient characteristics Characteristic Age (yr) Height (cm) Weight (kg) Intrauterine period (wk) 32.9±3.26 160.9±3.45 68.4±9.41 38.3±0.85 33.4±3.07 162.4±5.38 69.0±5.76 38.2±0.70 There are no significant differences between two groups. The values are presented as mean±sd. 84 THE EWHA MEDICAL JOURNAL
Kang YI, et al: Effect of Injection Speed of Spinal Anesthesia 군간에유의한차이가없었다 (Table 2). 척추마취차단높이는빠른군이 4.35±0.88 흉추분절, 느린군이 4.70±0.92 흉추분절로두군간에차이는없었으며마취시작시간도빠른군이 2.60±0.94분, 느린군이 3.10±0.91분으로두군간차이는없었다 (Table 2). Ephedrine 사용건수는빠른군에서 13명으로 65% 였고느린군에서는 15명으로 75% 로두군간에저혈압발생빈도는유의한차이가없었다. 총사용량은빠른군은 19.77±10.28 mg, 느린군은 17.87±8.13 mg으로두군간에유의한차이는없었다 (Table 3). 처음 ephedrine 사용시간은빠른군이 5.96±1.63분, 느린군이 7.17±3.26분으로유의한차이가있었다. 빠른군에서 1명이국소마취제주입후 7.5분에수축기혈압이 53 mmhg, 이완기혈압이 29 mmhg 발생하여 ephedrine을반복해서 40 mg을투여하였으나구토증상이심하고심혈관계반응이안정화되지않아 phenylephrine을 20 μg을사용하여혈압을상승시켰다. Table 2. Data between two groups Variable Spinal anesthesia Onset time (min) Level (thoracic dermatome) Neonate outcome Body weight (kg) Apgar score (1 min) Apgar score (5 min) Incision time (min) Delivery time (min) Fluid during 20 min (ml) 2.60±0.94 4.35±0.88 3.18±0.43 7.95±0.22 8.90±0.45 8.45±1.47 14.20±2.39 885.0±308.26 3.10±0.91 4.70±0.92 3.39±0.38 8.00±0.00 9.00±0.00 7.40±2.32 13.40±3.24 772.5±306.7 There are no significant differences between two groups. Values are presented as mean±sd. 척추마취시작전, 마취시작후 20분간수축기혈압, 이완기혈압, 심박수, 맥박산소포화도를 2.5분간격으로측정한결과두군간혈압하강정도에유의한차이는없었다 (Table 4). 오심, 구토는빠른군에서 7명 (35%) 발생하였고느린군에서는 5명 (25%) 발생하였으며두군간에유의한차이는없었다. 고찰 산모들은임신전보다혈액량이 40% 증가되어있으나부위마취를시행하게되면교감신경이차단되어말초혈관이확장되고심장으로의정맥혈류가감소하여심박출량이감소하며임신에의한자궁으로대정동맥이압박을받아저혈압발생이많다. 4번째흉추분절보다낮게교감신경이차단된경우차단이안된상부부위의혈관수축작용으로혈압하강이어느정도조절되는데제왕절개술의경우 4번째흉추분절이상마취를시행하게되므로차단높이가높을수록저혈압발생이더욱잘유발된다. 특히척추마취는경막외마취보다작용시간이빨라심혈관계보상발현 Table 3. Ephedrine data Variable Number of use Total amount (mg) First injection time (min) 13 (65%) 19.77±10.28 5.96±1.63* 15 (75%) 17.87±8.13 7.17±3.26* There are significant difference between two groups in the first ephedrine injection time but no differences in the number of use and amount of ephedrine. Values are presented as mean±sd. *P<0.05 between two groups. Table 4. Hemodynamic data in two groups Minutes 0 2.5 5 7.5 10 12.5 15 17.5 20 SBP (mmhg) DBP (mmhg) HR (beats/min) 117.2±26.6 122.8±10.1 78.1±7.8 78.0±8.0 80.1±15.3 86.9±20.8 115.7±11.2 120.6±15.0 70.2±8.0 71.4±12.6 85.7±13.1 86.1±17.7 106.1±11.3 107.9±16.2 64.4±10.3 61.4±11.9 91.1±12.2 87.8±18.1 104.2±13.5 105.8±20.5 60.4±9.3 60.1±13.2 91.3±14.9 90.0±22.8 105.9±15.8 111.8±15.2 61.9±11.7 63.5±9.8 84.0±18.1 90.9±24.5 112.3±11.7 111.4±16.4 68.2±7.6 64.9±11.2 79.6±15.5 89.1±25.8 118.6±14.0 124.0±17.3 70.3±9.9 69.4±4.1 79.8±14.9 86.3±24.8 123.5±11.3 121.9±12.7 72.0±8.1 67.5±11.2 75.5±10.7 84.7±18.5 122.2±8.1 117.8±10.5 69.6±6.9 65.7±12.2 83.0±10.5 88.4±16.2 There are no significant differences between two groups in SBP, DBP and HR. Values are presented as mean±sd. SBP, systolic blood pressure; DBP, diastolic blood pressure; HR, heart rate. THE EWHA MEDICAL JOURNAL 85
Ewha Med J Vol. 35, No. 2, 2012 시간이부족해저혈압발생률이높아진다. 척추마취시국소마취제주입속도와마취차단높이에대해서여러저자들은상관관계가없다고보고하고있다. Bucx 등 [6] 은 0.5% bupivacaine 3 ml를이용한척추마취에있어서천천히주입한경우가빠르게주입한경우보다마취높이가 1개의피부분절차이로낮았지만통계학적의미는없었다고보고하였다. Van Gessel 등 [8] 도 0.5% bupivacaine 2 ml를이용한등비중마취에서국소마취제주입속도가마취에미치는영향이없었으며, Prakash 등 [9] 도 0.5% bupivacaine 2 ml를이용한척추마취시국소마취제주입속도가마취차단에미치는영향은없다고보고하였다. 하지만국소마취제주입속도가마취차단높이에영향을준다는보고도있는데 Atchison 등 [10] 은고관절수술시 0.5% tetracaine을이용한저비중국소마취제 5 ml 주입시 10초동안주입한군보다 250초주입한군이마취높이가 4개의분절이낮게차단되고마취시간이길었다고보고하였다. Horloker 등 [11] 은고관절수술척추마취시 0.5% bupivacaine 5 ml를이용한저비중마취시 0.5 ml/sec와 0.02 ml/sec 두속도로국소마취제주입시빠른주입군에서마취차단이 4개피부분절높게형성되었다고보고하였다. 대부분고비중에비해저비중, 등비중국소마취제를이용한보고에서는국소마취제주입속도가마취차단높이에영향을준다는연구결과가많은데이는 0.5% bupivacaine을식염수와혼합하면서부피가늘어나주입속도가빠를수록소용돌이현상이생겨차단높이가높게올라가는것이아닌가한다. 척추강내로국소마취제를빠른속도로주입시소용돌이현상으로많이혼합되어척수액으로퍼지며천천히주입할경우에는국소마취제가주입구에정체되어차단높이가상승이안되고대신마취기간이오래지속될수있다고하였다 [10]. 천천히주입하는경우마취시작시간이긴것은노출된마취농도가많고마취높이가낮음으로인해혈관에흡수될수있는면적이작아제거가늦게되기때문이아닌가하며저비중용액을주입할때천천히주입하면소용돌이현상이덜생겨서주입액이층을형성하므로마취차단높이가덜상승하게된다 [2]. 척추마취시영향을미치지않는인자로주입속도를언급하고는있지만저비중마취인경우는예외로하는경우도있다 [5]. Holman 등 [12] 은척추모형을이용한고비중액분포에관한실험에서 0.1 ml/sec 이하의느린속도로 주입시소용돌이현상없이일정한주입흐름으로국소적으로약물이존재한다고보고하였다. Bourke 등 [13] 의연구에의하면주입속도가 0.017 ml/sec 이상인경우에국소마취제주입시소용돌이현상을만들게되는데속도가빠를수록소용돌이가더생겨퍼지게되고느린경우는소용돌이가덜생기면서척수액과섞이게된다. 너무빠르게주입하는경우마취차단높이가올라가저혈압발생이심할수있고너무느리게주입하게되면국소마취제가국소적으로존재하여차단높이가낮아수술시통증을느낄수있을것으로생각하여저자들은 0.02 ml/sec 느린군과 0.1mL/sec 빠른군을선택하여연구하였다. 이에반해 Tuominen 등 [14] 은오히려 0.17 ml/sec 속도로천천히주입한경우감각차단이높게된다는보고도있고오히려 0.5% bupivacaine을천천히주입한경우마취높이가상승했다는보고도있어 [7] 국소마취제주입속도뿐만이아니라농도, 용량, 부피, 환자의자세등다양한요소들이영향을미친다는것을알수있다. 또한국소마취제의온도도영향을줄수있는데 Davis와 King [15] 은국소마취제의온도가올라갈수록비중은감소하고부피는증가한다고보고하였으며 0.5% bupivacaine이실온에서는고비중이지만체온인 37 o C에서는등비중이되며 [16] 5 ml 주입액이 37 o C 도달하는데 3분이걸린다고하였다 [10]. 빠른주입보다천천히주입하는경우에있어비중의변화가와서국소마취제의이동에영향을줄수있다하였으나실제적은용량을짧은시간에주입하므로영향이적을것으로추측되며등비중, 저비중인경우보다고비중일때주입속도를빨리해야한다는주장도있다 [17]. 또한 Neigh 등 [18] 은바늘주입구방향의중요성을언급하였으며바늘방향을머리방향으로하고국소마취제를주입한경우마취차단이높게된다고보고하였다. 따라서저자들은다른조건들은동일시하고국소마취제주입속도만달리하여주입속도가저혈압발생빈도, 혈압하강정도, 마취차단높이, ephedrine 사용에영향을주는지연구를시작하였다. 본연구에서마취차단높이는빠른군이 2.60±0.94분에 4.35±0.88 흉추분절까지차단되고, 느린군은 3.10±0.91분에 4.70± 0.92 흉추분절까지차단되어두군간차이는없게나왔다. 저혈압발생은 40명중 28명에서발생하여 70% 의빈도를보였다. 저혈압발생은빠른군에서 13 명 (65%) 발생하였고평균 ephedrine 사용량은 19.77± 10.28 mg이며느린군에서는 15명 (75%) 발생하였고 86 THE EWHA MEDICAL JOURNAL
Kang YI, et al: Effect of Injection Speed of Spinal Anesthesia ephedrine 사용량은 17.87±8.13 mg으로두군간에유의한차이는없었다. 척추마취후발생한저혈압치료에는 α, β 교감신경수용체에작용하며자궁혈관은수축시키지않는 ephedrine을사용하며 ephedrine에반응이즉각적이지않는경우 phenylephrine을사용한다 [19]. Ephedrine은심박출량과말초혈관저항을회복시키지만반복투여시속성내성이생길수있음을유념해야하며 α교감신경수용체에만작용하는 phenylephrine 경우전신혈관저항을강력히증가시켜혈압을유지시키기때문에경우에따라서는심박출량이더욱감소할수있으므로전신혈관저항이심하게감소된경우에만선택적으로사용해야된다. 척추마취후저혈압에대한보상반응으로혈압유지를위해빈맥이발생하나간혹 1 4 흉추부위에서나오는교감신경성심장촉진섬유가차단되는경우또는정맥환류량의감소로인해우심방및대정맥에위치하는변시성신장수용기의자극으로서맥이발생하기도한다 [1]. 혈압하강의정도는두군간유의한차이는없었지만처음 ephedrine 투여시간은빠른군은 5.96± 1.63분이며느린군은 7.17±3.26분으로유의한차이가있었는데이는빠르게주입하는군에서저혈압발생이더빨리발생하였다. 마취시작시간에비해저혈압발생시간은 3 4분뒤에발생하였으며이는차단속도는차이가없지만저혈압발생시간에는영향을준다는것을의미한다. 이는빠른군에서저혈압발생시교감신경의보상작용발현시간이충분하지않음을의미한다. Simon 등 [2] 은산모의제왕절개술시 10 mg bupivacaine을사용하여척추마취시 15초로빠르게주입한경우보다 120초천천히주입한경우저혈압빈도도낮고마취시작도늦으며마취시간은짧으며 ephedrine 요구량이작았다고보고하였다. Cho 등 [20] 은 bupivacaine을이용한일측성마취연구에서느린속도로주입한경우일측성마취도성공하고혈역학적으로안정되었다고보고하였으며 Bouchnak 등 [21] 은 0.5 % bupivacaine을사용한경우 60초동안주입한경우 20초군보다저혈압발생이적었다고하였다. 본연구에서 0.5% bupivacaine 2 ml를 100초동안 0.02 ml/sec 속도로천천히주입하는군에서 20초동안 0.1 ml/sec 속도로빠르게주입하는군에비해차단높이나저혈압발생빈도, 혈압하강정도는별차이가없었으나저혈압발생시간은유의하게천천히주입하는군에서발생시간이늦었다. 통계학적의미는없었지만국소마취제를천천히주입하는군에서 ephedrine을적게사용하였으므로국소마취제주입시소용돌이현상과정체현상을고려하여적절한속도로주입하는것이필요하며가능한천천히주입하는것이산모의심혈관계안정을위해좋다고생각한다. 참고문헌 1. The Korean Society of Anesthesiologists. Anesthesia. Seoul: Koonja Inc.; 2002. 2. Simon L, Boulay G, Ziane AF, Noblesse E, Mathiot JL, Toubas MF, et al. Effect of injection rate on hypotension associated with spinal anesthesia for cesarean section. Int J Obstet Anesth 2000;9:10-14. 3. Ebner H, Barcohana J, Bartoshuk AK. Influence of postspinal hypotension on the fetal electrocardiogram. Am J Obstet Gynecol 1960;80:569-572. 4. Corke BC, Datta S, Ostheimer GW, Weiss JB, Alper MH. Spinal anaesthesia for Caesarean section: the influence of hypotension on neonatal outcome. Anaesthesia 1982;37:658-662. 5. Miller RD. Miller's anesthesia. 6th ed. San Francisco: Elsevier Inc.; 2005. 6. Bucx MJ, Kroon JW, Stienstra R. Effect of speed of injection on the maximum sensory level for spinal anesthesia using plain bupivacaine 0.5% at room temperature. Reg Anesth 1993;18:103-105. 7. Stienstra R, Gielen M, Kroon JW, Van Poorten F. The influence of temperature and speed of injection on the distribution of a solution containing bupivacaine and methylene blue in a spinal canal model. Reg Anesth 1990;15:6-11. 8. Van Gessel EF, Praplan J, Fuchs T, Forster A, Gamulin Z. Influence of injection speed on the subarachnoid distribution of isobaric bupivacaine 0.5%. Anesth Analg 1993;77:483-487. 9. Prakash S, Bhartiya V, Pramanik V, Pahilajani J, Gogia AR, Singh R. The effect of injection speed on the spinal block characteristics of hyperbaric bupivacaine 0.5% in the elderly. J Anesth 2010;24:877-881. 10. Atchison SR, Wedel DJ, Wilson PR. Effect of injection rate on level and duration of hypobaric spinal anesthesia. Anesth Analg 1989;69:496-500. 11. Horlocker TT, Wedel DJ, Wilson PR. Effect of injection rate on sensory level and duration of hypobaric bupivacaine spinal anesthesia for total hip arthroplasty. Anesth Analg 1994;79:773-777. 12. Holman SJ, Robinson RA, Beardsley D, Stewart SF, Klein L, Stevens RA. Hyperbaric dye solution distribution characteristics after pencil-point needle injection in a spinal cord model. Anesthesiology 1997;86:966-973. THE EWHA MEDICAL JOURNAL 87
Ewha Med J Vol. 35, No. 2, 2012 13. Bourke DL, Sprung J, Harrison C, Thomas P. High injection speed overwhelms other maneuvers for controlling the spread of spinal anesthesia. Anesth Analg 1995;81:427-428. 14. Tuominen M, Pitkänen M, Rosenberg PH. Effect of speed of injection of 0.5% plain bupivacaine on the spread of spinal anaesthesia. Br J Anaesth 1992;69:148-149. 15. Davis H, King WR. Densities of cerebrospinal fluid of human beings. Anesthesiology 1954;15:666-672. 16. Brown DT, Wildsmith JA, Covino BG, Scott DB. Effect of baricity on spinal anaesthesia with amethocaine. Br J Anaesth 1980;52:589-596. 17. Greene NM. Distribution of local anesthetic solutions within the subarachnoid space. Anesth Analg 1985;64: 715-730. 18. Neigh JL, Kane PB, Smith TC. Effects of speed and direction of injection on the level and duration of spinal anesthesia. Anesth Analg 1970;49:912-918. 19. The Korean Society of Obstetric Anesthesiologists. Obstetric anesthesia. Seoul: Koonja Inc.; 2009. 20. Cho HS, Son YS, Chung KD, Lee WH, Park JM, Chung JH, et al. The effect of injection speed of local anesthetic on success rate of unilateral spinal anesthesia. Korean J Anesthesiol 2005;49:793-797. 21. Bouchnak M, Belhadj N, Chaaoua T, Azaiez W, Hamdi M, Maghrebi H. Spinal anaesthesia for Caesarean section: dose injection speed have an effect on the incidence of hypotension? Ann Fr Anesth Reanim 2006;25:17-19. 88 THE EWHA MEDICAL JOURNAL